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THE  LIBRARIES 
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HEALTH  SCIENCES 
LIBRARY 


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OBSERVATIONS 


WOUNDS,  AND  THEIR  COMPLICATIONS  BY  ERYSIPELAS, 
GANGRENE  AND  TETANUS, 


AND  ON  THE 


PRINCIPAL    DISEASES    AND    INJURIES 


HEAD,  EAR  AND  EYE. 

BY  THE 

BARON  D.  J.  LARREY, 

LATE   SURGEON  IN  CHIEF  TO  THE  IMPERIAL'  isRAND  ARMY  IN  RUSSIA,  ETC.  ETC. 

WITH  PLATES. 

TRANSLATED   FROM  THE   FRENCH   BY 

E.  F.  RIVINUS,  M.D. 
KEY,   MIELKE   &  BIDDLE, 

181  MARKET   STREET. 

1832. 


Entered  according  to  the  act  of  congress,  in  the  year  1832,  by  Key,  Mielke 
&  £iddle,  in  the  clerk's  office  of  the  district  court  of  the  eastern  district  of  Peaa- 
sylvania. 


Philadelphia  : 

James  Kay,  Jun.  &  Co.,  Printers, 

No.  4,  Minor  Street. 


PREFACE  OF  THE  TRANSLATOR. 


In  reply  to  those  who,  conversant  with  the  writings 
and  literary  labours  of  the  Baron  Larrey,  are  desirous  to 
learn  when  he  composed  the  work  before  the  reader,  on 
the  ^^  Diseases  and  Injuries  of  the  Head,"  it  is  proper  to 
state  that  it  constitutes  the  first  volume  of  the  Baron's 
latest  work,  entitled  "  Clinique  Chirurgicale,  Paris,  1829 
— 1830."  Under  this  unassuming  title,  the  author  has 
embodied  in  three  volumes  that  immense  mass  of  surgical 
experience  which,  during  one  of  the  most  eventful  pe- 
riods in  the  history  of  man,  he  has  had  the  good  fortune 
to  make  in  four  quarters  of  the  globe,  under  the  auspices 
of  one  of  the  most  extraordinary  personages  who  ever 
wielded  the  destinies  of  mankind.  As  the  personal  friend 
of  Napoleon,  he  enjoyed  the  privilege  of  accompanying 
him  upon  all  his  principal  expeditions  and  campaigns, 
from  the  earliest  dawn  of  his  effulgent  career  to  his 
downfall,  which  our  author  himself  politically  survived; 
being  subsequently  retained  by  the  ruling  powers — a 
rare  tribute  paid  to  genuine  merit  without  distinction 
of  party — as  surgeon  in  chief  to  the  great  military  hospi- 
tal of  the  royal  guards.  Endowed  by  nature  with  un- 
common capacities  for  observation  and  philosophical 
induction  which  had  been  early  developed  by  the  illus- 
trious Sabatier,  his  preceptor,  he  improved  his  superior 
opportunities  with  the  most  becoming  spirit  of  industry 


iv  Preface  of  the  Translator. 

and  the  most  indefatigable  devotion  to  the  interests  of 
science  and  of  mankind. 

A  large  portion  of  the  numerous  surgical  facts  collected 
in  his  forty  years  service  has  already  been  recorded  by 
him  in  his  "Memoirs"  of  the  campaigns  in  w^hich  he 
served.  These,  however,  are  there  related  merely  in 
chronological  order,  loose,  incoherent  and  interspersed 
with  much  irrelevant  matter  of  purely  historical  interest. 
In  the  present  work,  on  the  contrary,  a  systematical 
arrangement  of  the  subject  matter  has  been  realized, 
supported  and  connected  by  the  author's  close  and  in- 
genious reasoning.  Thus,  preceded  by  some  general 
remarks  on  wounds  and  their  complications  by  erysipelas, 
gangrene  and  tetanus,  the  surgical  diseases  of  the  head, 
ear  and  eye  are  exclusively  treated  in  the  first;  those 
of  the  face,  neck,  and  trunk  in  the  second;  while  the 
subjects  of  hernia,  aneurism,  fracture,  amputation,  &c. 
&c.  are  separately  discussed  in  the  third  volume  of  the 
Clinique  Chirurgicale.  Each  volume,  therefore,  consti- 
tutes an  independent  whole,  and  considering  it  in  this 
point  of  view,  the  separate  publication,  under  the  espe- 
cial title  assigned  to  it,  of  the  first  volume  of  this  highly 
interesting  work,  will,  it  is  supposed,  require  no  apology. 
The  great  importance  of  the  subject,  which  is  far  from 
being  exhausted,  the  originality  of  the  author's  views  of 
the  pathology  and  treatment  of  several  leading  surgical 
diseases  of  the  head,  will  insure  it  a  respectful  considera- 
tion, and  the  evident  leaning  of  the  author  to  the  theories 
of  Dr  Gall  will  prove  an  additional  recommendation  to 
some,  while  it  will  tend  to  amuse  others. 

E.  F.  RIVINUS. 

Philadelphia,  August  1832. 


CONTENTS. 


A  General  View  of  Wounds^  especially  of  Gun-Shot  Wounds^      1 
Incised  wounds,  .  .  .  .  .3 

Sutures,  .  .  .  .  .  .4 

Punctured  wounds,        .  .  .  .  .7 

Lacerated  wounds,        .  .  .  .  .8 

Wounds  inflicted  by  rabid  animals — Hydrophobia,  .        9 

Poisoned  wounds,  .  .  .  .  .16 

Gun-shot  wounds,  .  .  .  .  .20 

Complications  of  vvounds — Eccliymosis,  .  .        5 

Traumatic  fever,  .  .  .  .  .26 

Injuries  of  nerves,         .  .  .  .  .27 

Foreign  bodies,  .  .  .  .  .28 

Treatment  of  gun-shot  wounds,  .  .  .35 

Traumatic  erysipelas,  .  .  .  .      39 

Abscesses,  or  purulent  sinuses,  subsequent  to  wounds,  48 

Hospital  gangrene,        .  .  .  .  .48 

Gangrene,        .  .  .  .  .  .52 

Tetanus,  .  .  .  .  .  .54 

Cases  of  partial  and  general  tetanus,     .  .  .71 

Cases  of  the  efl^ects  of  pressure  from  a  ligature  upon  a 

nerve  and  of  the  influence  of  cold  and  moist  air,  .  72 
Case  of  laceration  of  nerves,  and  of  the  utility  of  incisions,  74 
Cases  of  compression  and  turgescence  of  nerves  occasioned 

by  their  adhesion  to  the  cicatrix  of  a  wound,  .       75 

Cases  of  tetanus  treated  principally  by  internal  remedies,      78 
Cases  of  tetanus  in  which  some  peculiar  phenomena  had 

appeared,      .  .  .  .  .  .82 

Case  of  traumatic  tetanus  excited  by  the  coolness  of  the 

nights,  and  aggravated  by  a  moral  afl^ection,  .       84 

Cases  of  the  advantages  arising  from  the  amputation  of  the 

injured  limb  in  tetanus,  ...  85 


vi  Contents. 

Instances  of  ilie  eiTicacy  of  the  remedies  best  calculated  to 
ward  off  the  tetanic  symptoms  which  are  likely  to  result 
from  an  amputation,  .  .  •  .88 

Diseases  and  Injuries  of  the  Head,  .  .  .91 

Mechanical  injuries  of  the  cranium  and  of  the  different 

parts  of  the  encephalon,         .  .  •  .91 

Compression  of  the  anterior  or  superior  periphery  of  the 
brain,  resulting  in  the  loss  of  the  senses,  and  in  a  per- 
ceptible decline  of  the  intellectual  faculties,  .       95 
Compression  of  the  base  of  the  brain,  giving  rise  to  symp- 
toms of  paralysis,       .              .              .              •  .96 
Partial  loss  of  memory,                ....     109 

Curability  of  injuries  of  the  brain,  .  .  .126 

Actual  cautery  of  the  meningeal  arteries,  .  .127 

Venous  inhalation,         .  .  .  .  .128 

Neuralgic  affections  of  the  head  caused  by  injuries  of  the 
internal  parietes  of  the  cranium  and  by  laceration  and 
inflammation  of  the  meninges,  .  .  .131 

Injuries  of  the  head  requiring  the  trephine,         .  .     140 

Cases,  showing  the  necessity  of  extracting  foreign  bodies, 
by  some  means  or  other,  and  of  evacuating  the  fluids 
effused  within  the  cranium,  .  .  .147 

Cases  showing  the  necessity  of  the  application  of  the  tre- 
phine in  the  instance  of  fractures  of  the  bones  of  the 
cranium,  with  depression  of  the  fractured  pieces,  and 
with  lesion  of,  or  pressure  upon,  the  dura  mater  and 
brain,  ......     159 

Injuries  of  the  head  where,  contrary  to  the  opinion  of  most 
writers,  the  trephine  is  not  only  useless,  but  may  be 
even  attended  with  danger,  .  .  .171 

Singular  facts,  proving  that  the  trephine  should  not  be 
employed  in  all  cases  where  foreign  bodies  have  entered 
into  the  cranium,  •  .  .  .175 

Treatment  of  hernia  cerebri,  .  .  .179 

Causes  of  abscesses  of  the  liver,  subsequently  to  injuries 
of  the  head,  .  .  .  .  .181 

Of  apoplexy,  .  .  .  .  .195 

Injuries  of  the  cerebellum  in  man,  .  .  .199 


Contents.  vii 

Effects  of  these  injuries  upon  the  organs  of  generation,       202 
Effects  of  the  diseases  of  the  genital  organs  upon  the  cere- 
bellum,       ......      202 

Of  Nostalgia,        .  .  .  .  .  .218 

Remarkable  cases  of  nostalgia,  .  .  .      224 

Of  venesection  from  the  jugular  vein,  .  .      240 

Of  arteriotomy,  .....      242 

Of  the  nervous  system  of  relation,         .  .  .       243 

Soemmering's  electrical  telegraph,       .  •  .       243 

Injuries  of  Certain  Parts  of  the  Face.,      .  .  .      250 

1.  Lesions  of  the  ear,  ....       250 

Uneven  and  jagged  wounds  of  the  external  ear,  250 

Foreign  bodies  introduced  into  the  ear,     .  .       253 

Cause  of  deafness  consisting  in  some  particular  mal- 
formation, ....       254 
Remarks  upon  the  surgical  perforation  of  the  mem- 
brana  tympani,  ....       269 

2.  Of  some  diseases  of  the  eyes,  .  .  .261 

Wounds  of  the  eye-brows,  .  .  .261 

Wounds  of  the  eye-lids,  .  .  .       262 

Anatomical  structure  of  the  conjunctiva,  .      263 

Ofchemosis,        .....      265 
Peculiar  affection  of  that  part  of  the  conjunctiva  which 
surrounds  the  carunculas  lachrymales,  common  in 

Egypt, 266 

Injury  of  the  lachrymal  gland  from  a  gun-shot  wound,    267 
Fistula  lachrymalis,  ....       268 

Changes  of  structure  in  the  ball  of  the  eye,  .      271 

Cases  of  wounds  and  of  concussions  of  this  organ,      271 
Of  the  properties  of  the  iris  and  the  want  of  connexion 
existing  between  this   membrane   and  the  direct 
organs  of  vision,  the  optic  nerves  and  the  retina,       282 
Of  iritis,  .  .  .  .  .290 

Physiological  explanation  of  the  causes  of  motion  of 

the  pupil,         .  .  .  .  .294 

Of  ophthalmia,  and  especially  of  the  endemic  ophthal- 
mia of  Egypt,  ....       298 


viii  Contents. 

Causes  of  ophthalmia,      ....  302 
Treatment  of  ophthalmia,            .             .             .312 

Of  Epilepsy,         ......  317 

Diagnosis  of  genuine  from  feigned  epilepsy,                  .  320 

Treatment,                   .....  322 

Cases  of  epilepsy,                    .             .             .             .  323 


OBSERVATIONS 


WOUNDS,  AND  ON  THE   PRINCIPAL   DISEASES  AND 
INJURIES  OF  THE  HEAD. 


Â  General  View  of  Wounds,  especially  of  Gun-shot 
Wounds. 

Before  I  undertake  to  collect  and  methodically  to  arrange 
those  numerous  observations — the  results  of  my  researches  and 
labours  amongst  the  numerous  surgical  diseases  which,  during 
the  memorable  war  on  the  four  continents,  I  have  had  oc- 
casion to  treat  in  the  camp,  as  well  as  in  hospitals,  I  intend 
to  indulge  in  a  few  remarks  on  the  solutions  of  continuity,  by 
which  our  limbs  are  liable  to  be  injured,  notwithstanding 
that  these  complaints  have  been  before  described  by  the  clas- 
sical writers.  I  shall  more  particularly  direct  my  attention  to 
the  nature  of  gun-shot  wounds,  and  to  the  treatment  suited  to 
them.  Appealed  to  by  the  piercing  cries  which  the  feelings 
of  pain  extort  from  the  wounded  left  on  the  field  of  battle,  at- 
tracted by  the  plaintive  voice  of  the  dying,  and  above  all 
desirous  of  rendering  the  rules  to  be  pursued  useful  to  their 
utmost  extent,  I  never,  from  the  first  commencement  of  the 
hostilities  of  that  war,  dreaded  to  carry  the  comforts  of  my  art 
in  the  midst  of  the  combatants.  It  was  then  that  I  created 
those  light,  itinerant  hospitals,  which  have  so  much  reduced 
the  number  of  victims  to  the  deadly  blows  of  the  fatal  sisters; 
and  it  was  then,  also,  on  the  fields  of  glory  and  carnage,  if  I 
may  venture  thus  to  express  myself,  that  I  became  convinced 
of  the  necessity  of  operating,  immediately,  upon  those  whose 
A 


2  A  General  View  of  Wounds, 

limbs  had  been  mutilated  or  destroyed  by  projectile  weapons. 

Without  the  prompt  application  of  this  maxim,  how  many 
generous  defenders  would  have  met  the  fate  of  those  soldiers 
who,  in  previous  wars,  were  not  till  some  time  after  carried  from 
the  field  of  battle,  and  even  then,  only  when  the  hospital  wagons, 
heavy  at  that  time,  and  more  or  less  encumbered  in  their  move- 
ments, had  arrived  on  the  spot,  in  order  to  pick  them  up,  and  to 
remove  them  to  the  hospitals,  the  only  place  where  operations  at 
all  important  were  performed  !  They  whose  wounds  would 
have  entitled  them  to  the  benefits  of  these  wagons,  in  a  few  mo- 
ments, or  in  a  few  hours,  after  receiving  the  shot,  had  already 
ceased  to  exist;  and  as  to  those  who,  after  the  first  shock,  were 
found  to  be  still  alive,  there  was  then,  indeed,  sufficient  rea- 
son to  believe  that  their  recovery  would  be  the  more  certain, 
as  the  operations  which  might  be  indicated,  would  not  be  per- 
formed till  after  the  cessation  of  every  unfavourable  symptom. 
Now,  it  is  from  wounds  of  this  nature  (for  the  relief  of  which 
they  had  arrived  too  late,  or  which,  in  consideration  of  the  de- 
velopment of  certain  symptoms,  required  great  circumspec- 
tion,) that  the  surgeons  of  the  last  century  undertook  to  justify, 
in  all  cases,  the  propriety  of  dilatory  operations,  and  had  ar- 
rived in  this  respect  to  the  solution  of  that  great  problem,  so 
long  proposed  and  agitated  by  the  royal  academy  of  surgery;  a 
problem  which,  even  to  this  day,  is  looked  upon,  by  several 
distinguished  members  of  the  profession,  in  the  same  light 
as  by  that  illustrious  society.  None  of  these  surgeons,  how- 
ever, have  been,  I  venture  to.  say,  eye-witnesses  of  those 
mutilations,  and  of  those  great  physical  disorders  which  fire- 
arms are  apt  to  produce  in  the  course  of  obstinate  engage- 
ments, where  every  inch  of  ground,  or  every  broken  line  of 
fortification  is  disputed  almost  hand  to  hand.  For,  although  the 
din  of  war  did  resound  within  the  heart  of  our  own  capital, 
yet  I  may  well  say  that  the  results  of  the  combats  which  took 
place  under  her  walls,  would  never  have  compared  to  those 
sanguinary  battles  which  dyed  the  fields  of  Italy,  Egypt,  Ger- 
many, Poland,  Spain  and  Russia,  with  human  blood.  To  the 
circumstance,  therefore,  of  having  carried  the  principles  of  the 
former  academy  into  efiect,  so  far  as  regards  the  small  number 


Incised  Wounds.  3 

of  the  defenders  of  this  large  city  (Paris)  whose  wounds  had 
rendered  several  great  operations  necessary,  is  it  to  be  ascribed, 
that  their  success  has  not,  in  general,  responded  at  all  to  the 
expectations  of  our  surgeons.  Confining  myself,  for  the  pre- 
sent, to  this  observation,  I  propose  to  treat  this  important 
subject  at  full  length,  in  the  article  appropriated  to  it,  and 
without  losing  sight  of  the  principles  of  science,  I  shall  per- 
mit experience  to  speak  for  herself,  the  results  of  which  I 
would  especially  offer  to  young  military  surgeons. 

Of  Incised  Wounds. 

Wounds  are  recent  solutions  of  continuity  inflicted  upon 
our  limbs  by  some  cause  or  other,  which  destroy  their  integ- 
rity. If  the  wound  is  the  result  of  a  very  sharp-edged  cutting 
instrument,  it  requires  nothingbut  a  reunion.  Supposing,  then, 
that  only  the  skin  and  the  muscles  are  divided,  the  first  phe- 
nomenon presented  by  such  a  wound,  is  the  retraction  of  these 
parts,  which  is  effected  by  virtue  of  their  elasticity  and  con- 
tractility. In  order  to  render  the  reunion  accurate,  and  but 
little  painful  to  the  feelings,  it  is  requisite  first  to  separate  the 
corners  of  such  a  wound,  and  to  draw  its  edges  close  together. 
For  this  purpose  the  divided  and  subjoined  parts  must  be  put 
into  a  state  of  the  most  perfect  relaxation,  while  those  which 
are  diametrically  opposed  to,  and  the  antagonists  of,  the  latter, 
should  be  stretched  to  the  utmost. 

The  means  to  be  employed  to  achieve  a  reunion  consist  in 
aiding  the  effects  of  the  position  of  the  part,  in  guarding  against 
its  displacement,  and  in  bringing  the  lips  of  the  wound  in 
close  apposition.  When  the  skin  only  is  divided,  any  force 
bearing  upon  it  will  be  sufficient,  and  this  indication  will, 
therefore,  be  best  accomplished  by  adhesive  strips,  supported 
by  compress  and  bandage.  And  on  this  occasion  1  would  ob- 
serve that,  after  having  leaned  the  wound,  the  most  simple 
and  most  proper  plan  is  to  close  it,  and  to  let  it  alone  till  there 
is  reason  to  think  that  it  has  cicatrized,  and  this  with  a  view 
to  prevent  the  air  from  coming  in  contact  with  it,  which  must 
always  prove  injurious,  as  has  been  too  frequently  verified 
by  experience.  Agreeably  to  the  same  experience,  therefore, 
or  to  some  immemorial  tradition,  the  majority  of  the  savages 


4  Incised  Wounds— Shitures. 

of  the  new  and  the  old  world,  as  well  as  the  Arabians  of  Egypt, 
immediately  after  having  received  their  wounds,  cover  them 
up  with  some  kind  of  taffeta,  dipped  into  a  balsam,  which 
they  allow  to  remain  on  it,  till  the  wound  has  completely  heal- 
ed, a  result  which  generally  is  accomplished  without  further 
efforts,  and  within  a  ver}'  short  space  of  time. 

In  order  to  unite  the  divided  muscles,  and  keep  them  in 
contact,  the  employment  of  such  means  is  required  as  will  bear 
upon  their  whole  extent,  hold  them  compressed,  and  retain 
them  constantly  in  the  position  in  which  the  wounded  part 
has  been  placed.  The  uniting  bandage  presents  these  three 
advantages.  It  accommodates  itself  to  the  shape  and  situation 
of  the  wound,  and  is  particularly  adapted  to  transverse  wounds 
of  the  limbs. 

When  the  solution  of  continuity  is  such  that  the  means  just 
mentioned  are  insufficient,  a  more  efficacious  remedy  must  be 
resorted  to.  This  is  a  suture,  which  now  becomes  indispensa- 
ble, because  of  the  want  of  support  afforded  by  the  parts  to  the 
bandage,  in  consequence  either  of  the  extent  of  the  wound,  and 
the  impossibilityof  retaining,  by  any  othermeans,  the  edgesclose 
together,  or  in  consequence  of  the  constant  action  and  retrac- 
tion of  the  parts,  all  which  may  happen,  for  example,  in  the 
extensi've  and  longitudinal  wounds  of  the  abdomen,  in  those 
which  divide  the  tender  coverings  of  the  mouth,  and  other 
parts  of  the  head,  the  neck,  and  the  trunk,  and  in  some  cases 
even  of  a  deep,  and  very  extensive  division  of  the  muscles  of 
the  extremities. 

A  suture  is  that  kind  of  surgical  operation,  which,  with  the 
aid  of  one  or  more  needles,  armed  with  a  flat  cord  of  waxed 
thread,  brings  the  two  lips  of  a  wound  into  immediate  contact. 
In  order  to  give  an  idea  of  the  nature  and  shape  of  the  needles, 
I  will  briefly  refer  to  my  memoir  on  the  subject  of  these  in- 
struments, to  which  an  accessit  to  the^rand  prize  was  awarded 
by  the  former  royal  academy  of  surgery. 

In  that  memoir  I  endeavoured  to  point  out,  first,  the  incon- 
veniences of  the  needles  which,  till  then,  had  been  constantly 
in  uss;  after  which  I  described  those  invented  by  myself,  and 
explained  the  advantages  which  they  present.  They  are  of 
fine  steel,  and  good  temper;  and  it  is  necessary  for  the  sutures 


Incised  Woujids — Sutures.  5 

of  the  different  wounds  of  the  abdomen,  neck,  face,  ears  and 
eye-lids,  to  have  large,  middle-sized,   small,  and  very  small 
needles.     They  are  curved  after  the  manner  of  a  semicircle, 
with  the  extremities  parallel  to  each  other.     The  point  has  the 
shape  of  a  small  spear  or  pike,  slightly  bent,  is  extremely  sharp, 
and  supplied  with  cutting  edges.     The  edges  terminate  towards 
the  body  of  the  needle  in  two  rounded  angles,  forming  upon  it 
a  projection  more  or  less  perceptible,  according  to  the  size  of 
the  instrument.     The  body  is,  throughout  its  whole  extent,  of 
equal  breadth  and  thickness;  both  its  surfaces  are  polished,  and 
its  sides  are  rounded  off,  and  rather  more  slender  than  the  centre. 
The  extremity  opposite  to  the  point,  or  the  head,  is  pierced 
by  a  transverse  and  square  opening,  which  is  about  two  and  a 
half  lines  distant  from  this  extremit}'',  and  is  hollowed  out  by 
a  plain  groove,  for  the  purpose  of  lodging  the  cord  or  thread. 
These  needles  enter  the  skin  with  ease,  and  make  only  a  sim- 
ple wound,  in  which  the  ligature  is  free,  and  preserves  that 
flattened  shape  which  so  perfectly  secures  the  lips  of  the  rent. 
.  These  small  wounds,  thus  produced  by  the  needles,  are  never 
accompanied  by  any  unpleasant  symptoms,  and  cicatrize  very 
promptly  as  soon  as  the  ligature  is  withdrawn. 

By  comparing  these  needles  with  those  formerly  and  now  in 
use,  it  will  be  easy  to  point  out  the  difference  which  exists  be- 
tween them,  and  to  appreciate  the  advantages  presented  by 
those  which  pass,  without  any  difficulty,  through  the  dense  and 
elastic  membrane  of  the  skin,  where  they  make  only  such 
wounds  as  resemble  those  which  are  occasioned  by  the  lancet. 
I  have  employed  these  needles  a  great  many  times,  and  al- 
ways with  the  greatest  facilit3^  * 

The  sutures  are  divided  into  the  interrupted,  the  quilled  or 
compound,  the  twisted  and  the  glover's  suture.  The  first  is 
suited  to  almost  every  case  where  a  suture  is  indicated;  the  se- 

•  I  have  presented  also  to  the  same  academy  another  needle  for  aneurism, 
which  only  differs  from  the  former  in  the  point,  which  is  blunt,  sufiBciently  slen- 
der and  rounded,  so  as  to  push  it  readily  through  the  cellular  tissue,  without  at 
the  same  time,  being  able  to  prick  the  nervous  cords,  or  cutting  the  collateral 
branches  of  the  artery  which  is  to  be  secured.  The  opening,  destined  to  accom- 
modate the  little  thread,  is  fixed  similarly  to  that  of  the  suture  needle.  The  liga- 
ture  needle  i»  only  somewhat  flexible,  (hat  it  may  describe  the  circuits  moie 
easily,  which  sometimes  it  is  compelled  to  make. 


6  Incised  Wounds- 

cond  is  chiefly  employed  in  wounds  of  the  abdomen;  the  twist- 
ed is  used  in  the  operation  for  hare-lip,  and  the  others  in  wounds 
of  the  stomach  and  the  intestines. 

As  soon  as  the  first  indications  are  fulfilled,  it  will  be  neces- 
sary to  aid  the  exertions  which  nature  makes  for  the  wound, 
from  the  first  moment  to  the  perfect  cicatrization,  and  which 
she,  by  imperceptible  agencies,  accomplishes  in  the  following 
manner: 

In  the  first  moments,  the  irritation  of  the  parts  establishes 
a  more  or  less  considerable  inflammatory  action  in  the  thick- 
ness of  the  lips  of  the  wound,  by  which  their  volume  is  in- 
creased; this  condition  is  accompanied  by  some  slight  pain, 
tension  and  heat,  which  after  some  time  terminates  by  reso- 
lution, or  by  a  purulent  or  serous  discharge.  After  this  the 
margins  subside,  the  vessels  become  disengaged,  form  adhe- 
sions, chiefly  by  inosculation,  and  establish  an  intercourse  be- 
tween themselves  which  is  more  or  less  perfect,  and  admits  of 
the  circulation  and  communication  of  the  fluids  of  both  sides. 
When  there  is  a  loss  of  substance,  the  cicatrix  is  sunk,  tender 
and  ready  to  break  or  tear,  which  disproves  the  theory  of  the 
reproduction  of  the  flesh. 

In  order  to  encourage  nature  in  her  efibrts,  the  patient  must 
be  directed  to  keep  the  most  absolute  rest,  regimen  and  diet, 
and  to  make  use  of  such  topical  applications  as  may  be  calcu- 
lated to  diminish  the  inflammation,  if  that  should  run  very 
high,  assuage  the  pain,  and  promote  the  union  of  parts.  This 
object  is  best  accomplished  by  allowing  the  first  dressing  to 
remain  as  long  as  possible. 

Authors  have  bestowed  the  name  of  comjiound  wounds 
upon  such  wounds  which  divide  the  soft  as  well  as  the  solid 
parts.  This  distinction  is  entirely  useless,  for  unless  the  di- 
visions are  attended  by  fracture,  splinter  or  contusion  of  bone, 
the  indications  and  the  treatment  are  the  same  as  for  simple 
wounds. 

The  complicated  wound,  however,  is  a  solution  of  conti- 
nuity, accompanied  by  circumstances  more  or  less  serious, 
which  present  new  indications.  These  complications  may  de- 
pend  upon  the  causes  which  produced  the  wound,  upon  the 


Incised  Wounds — Punctured  Wounds.  7 

symptoms  which  accompany  it,  or  upon  some  other  complaint 
with  which  the  patient  has  been  seized,  as  erysipelas,  phleg- 
mon, &c. 

When  the  whole  or  a  part  of  the  substance,  which  produced 
the  solution  of  continuity,  has  remained  in  the  flesh,  it  consti- 
tutes a  complication,  known  by  the  name  of  foreign  bodies. 
Now,  in  as  much  as  the  presence  alone  of  such  foreign  bodies 
may  develope  all  the  symptoms  above  alluded  to,  it  is  highly 
necessary  to  extract  them  immediately,  lest  the  means  which 
may  be  requisite  for  the  accomplishment  of  this  object  are  pro- 
ductive of  greater  injury  to  the  patient,  than  the  retention  in 
the  parts  of  these  foreign  bodies  themselves. 

We  do  not,  at  present,  mean  to  dwell  upon  these  dijSerent 
complications,  because  we  shall  have  occasion  to  speak  of  them 
more  at  large  in  the  account  which  we  propose  to  give  of 
gun-shot  wounds. 

For  the  present,  we  will  continué  our  remarks  on  the  solu- 
tions of  continuity,  called  after  the  causes  which  inflict  them; 
and  these  are  punctured  wounds,  lacerated  wounds,  and 
wounds  produced  by  the  bites  of  rabid,  or  venomous  animals. 

Punctured  Wounds. 
Punctures  being  the  efiect  of  the  action  of  a  more  or  less 
pointed  instrument,  difler  as  to  the  nature  of  the  instrument 
which  has  caused  them,  and  as  to  the  parts  which  have  been 
injured.  They  are  mostly  attended  by  a  higher  or  lesser  de- 
gree of  local  irritation  and  inflammation,  and  sometimes  by  ex- 
tremely serious  nervous  symptoms,*  of  which  we  shall  have, 
hereafter,  occasion  to  speak,  in  the  article  on  stings  of  certain 
insects  and  venomous  serpents.  Wounds  of  this  nature  require 
the  enlargement  of  the  injured  parts,  the  absorption  of  the 
effused  fluids,  a  proper  degree  of  compression,  and  the  anti- 
phlogistic regimen.  The  enlargement  being  made,  according 
to  circumstances,  cupping-glasses  may  be  applied  over  these 
wounds  with  great  advantage,  the  effects  of  which  may  be  in- 

*  Free  from  this  objection,  however,  are  the  punctures  made  by  (hose  very 
fine  acupuncturation  needles,  which  are  made  to  pass  readily  and  without  pain 
through  the  sheaths  of  the  muscular  tissue. 


8  Lacerated  tVounds. 

creased,  moreover,  by  scarifications  more  or  less  deep,  as  ne^ 
cessity  seems  to  require,  and  with  these,  appropriate  topical 
applications  may  be  combined,  such  as  compresses  and  dress^ 
ings,  soaked  in  some  sedative  and  discutient  lotion. 

Lacerated  Wounds. 

Lacerated  wounds  differ  from  other  solutions  of  continuity 
in  the  shape,  the  phenomena  which  they  present,  and  the 
symptoms  by  which  they  are  followed.  They  are  commonly 
very  irregular,  and  present  the  fragments  of  the  parts  separated 
from  one  another  and  more  or  less  retracted,  according  to  the 
contractility  of  these  parts;  the  lips  of  such  wounds,  formed 
by  the  integuments,  are  usually  turgescent  and  inverted. 
There  is  seldom  any  hemorrhage,  because  the  ruptured  arte- 
ries curl  upon  themselves,  and  because  their  coats,  which 
speedily  become  inflamed,  form  mutual  adhesions,  and  thus 
prevent  a  sanguineous  evacuation.  The  pain  is  sharp  and  ex- 
tends far  beyond,  more  particularly  along,  the  course  of  the 
nerves,  and  is  frequently  accompanied  by  a  vibratory  motion 
of  the  subjacent  parts,  and  by  a  certain  degree  of  numbness. 

Inflammation,  er'ethismus,  convulsive  twitches,  sometimes 
tetanus,  subsequent  accumulations  of  matter  and  purulent 
sinuses, — such  are  the  consequences  of  these  kinds  of  solutions 
of  continuity,  of  which  fortunately  not  often,  but  still  too  many 
instances  occur. 

They  may  be  the  result  of  a  limb,  or  some  portion  of  it  be- 
ing torn  off.  I  have  seen  many  horsemen  who  have  had  one 
or  more  of  their  fingers  torn  off,  when,  while  in  the  act  of 
watering  their  horses,  they  imprudently  held  them  by  the 
very  thin  reins  twisted  around  their  fingers.  The  horses 
becoming  frightened,  and  suddenly  starting,  make  an  effort 
upon  the  reins  which  hold  them  back,  so  rough  and  vio- 
lent, that  its  force  overcomes  the  resistance  of  the  hand  of 
the  rider,  and  that  not  only  the  finger  is  torn  off  at  the  stran- 
gulated articulation,  but  even  the  tendons  which  are  attach- 
ed to  the  extremity  of  this  appendix,  are  separated  up  to  their 
insertion  into  the  muscular  parenchyma. 

The  first  indications  to  be  fulfilled  consist  in  making  di- 


Wounds  inflicted  by  Rabid  Animals.  9 

vergent  incisions  through  the  integuments  which  form  the 
edges  of  the  wounds,  through  the  fibrous  sheaths  and  through 
the  aponeuroses;  in  cutting  out  all  those  disorganized  shreds 
of  muscle  or  tendon  which  protrude  beyond  the  level  of  the 
solution  of  continuity,  and  in  tying  as  much  as  possible  all 
vessels  which  are  visible,  as  well  as  those  after  which  search 
may  be  made  without  danger.  After  this  the  edges  of  the 
wound  are  to  be  drawn  together,  yet  without  being  over  anx- 
ious about  effecting  a  too  speedy  union  of  them;  while  at  the 
same  time  equal  pressure  is  to  be  made  over  the  whole  wounded 
surface  by  means  of  a  compress,  soaked  in  some  sedative  and 
gently  tonic  lotion;  and  this  dressing  is  to  remain  undisturbed 
as  long  as  possible,  without  being  renewed. 

Of  Wounds  inflicted  by  Rabid  Animals. 

The  wounds  produced  by  rabid  animals  are  unequal  and 
contused  solutions  of  continuity,  accompanied  by  smart  pain, 
and,  generally  speaking,  by  all  those  symptoms  which  super- 
vene in  punctured  wounds  in  which  a  poisonous  substance  has 
been  made  to  enter.  Yet  before  pronouncing  upon  the  state 
of  the  animal  which  has  inflicted  the  wound,  it  is  all  important 
to  learn  the  signs  and  symptoms  by  which  its  madness  may 
be  recognized  (for  which  purpose  the  authors  that  have  profess- 
edly written  on  hydrophobia  may  be  consulted). 

The  more  decisive  symptoms  which  are  apt  to  attack  man  in 
this  disease,  show  themselves  almost  never  immediately  after 
the  bite;  sometimes  an  interval  of  thirty  to  forty  days  elapses 
before  their  appearance;  but  at  other  times  they  come  on  within 
the  first  twenty-four  hours.  The  injury  itself  presents  only 
the  appearance  of  a  simple  contused  wound,  into  which  almost 
always  a  greater  or  lesser  quantity  of  the  saliva  of  the  animal 
has  insinuated  itself;  and  the  depravity  of  this  fluid  is  so  great, 
that  to  its  passage  into  all  parts  of  the  individual  must  the  symp- 
toms be  attributed  which  we  are  about  to  describe. 

This  wound  is  attended  with  pain,  some  degree  of  numbness 

in  the  part,  and  more  or  less  inflammation  :  the  parts  gradually 

begin  to  swell;  the  patient  evinces  a  state  of  anxiety;  the  eyes 

assume  a  haggard  aspect;  the  tears  flow  involuntarily;  the  com- 

B 


10  Wounds,  ^'C. — Hydrophobia. 

plexion  becomes  discoloured;  his  strength  begins  to  fail  him; 
and  his  slumbers  are  disturbed  by  terrifying  dreams;  he  loses 
his  appetite,  retires  from  society  and  seeks  solitude;  he  avoids 
the  broad  light  of  day,  and  shrinks  from  every  kind  of  drink 
or  fluid;  at  times  he  is  sorrowful,  sinks  into  some  sort  of  stu- 
por, from  which  he  awakes  by  starts,  and  becomes  furious 
in  some  degree;  he  experiences  an  oppression  at  the  heart,  a 
slight  difficulty  of  breathing,  twitches  in  all  his  limbs,  and 
suffers  from  a  kind  of  strangulation  which  is  still  more  in- 
creased by  the  high  temperature  of  the  body,  headach,  oc- 
casional vertigo,  and  more  or  less  violent  febrile  symptoms 
which  supervene  in  their  turn. 

All  these  symptoms  which  rapidly  increase  are  soon  follow- 
ed by  those  which  characterize  the  stage  of  frenzy:  the  patient 
evinces  a  propensity  to  rush  upon  his  fellow  beings  in  order 
to  bite  tbem,  or  he  endeavours  to  strangle  them,  not,  however, 
without  giving  previous  notice  of  his  intention  by  doleful 
screams,  or  menaces  peculiar  to  the  patients.  The  sight  of 
water  makes  a  disagreeable  and  fearful  impression  on  him;  it 
is  an  abomination  to  him,  which  manifests  itself  by  convulsed 
gestures.  He  experiences  the  greatest  difficulty  in  swallow- 
ing; his  saliva  flows  outward,  becomes  white  and  frothy,  simi- 
lar to  that  of  animals:  it  is  at  this  period  that,  with  the  ma- 
jority of  subjects,  several  bluish  vesicles  show  themselves, 
which  we  believe  to  be  peculiar  to  the  partial  turgidity  of  the 
ranine  veins,  and  the  opening  of  which  might  be  of  service  to 
the  patient,  by  abstracting  a  portion  of  the  blood,  with  which 
they  are  commonly  charged.  He  mechanically  carries  the  hand 
towards  the  throat,  as  if  he  wished  to  indicate  the  seat  of  his 
complaint;  he  refers,  indeed,  to  this  point  almost  all  the  suffer- 
ings which  he  experiences  during  its  continuance;  and  it  seems 
as  if  its  primary  cause  had  fixed  itself  chiefly  upon  the  nerves 
of  the  pharynx  and  larynx,  for  repeated  post  mortem  examina- 
tions have  demonstrated  to  us  that  these  parts  are  the  most 
affected.  The  whole  system  becomes  irritated  and  inflamed; 
the  different  organs  become  totally  deranged;  the  muscles  are 
seized  with  frightful  convulsions;  the  heat  and  fever  arrive  at 
;their  greatest  height,  and  the  patient  perishes  under  the  most 


PVoundSf  ^c. — Hydrophobia.  11 

dreadful  tortures  on  the  seventh,  ninth,  or  eleventh  day,  from 
the  appearance  of  the  first  symptoms;  he  rarely  survives  the 
thirteenth  day. 

It  is  diiFicult  to  explain  how  the  virus  of  madness  can  lie 
dormant  in  our  bodies  more  or  less  long,  subsequently  devel- 
ope  itself,  and  finally  terminate  under  such  awful  consequences. 
It  would,  nevertheless,  seem  that  this  virus,  which  is  of  a  very 
subtle,  but  unknown  nature,  must  have  a  particular  affinity  for 
the  nerves,  and  spread  itself  in  preference  over  the  nervous 
system,  where  it  can  remain  latent  for  a  greater  or  lesser  space 
of  time,  most  commonly,  as  we  have  already  stated,  for  thirty 
or  forty  days.  Its  effects,  as  soon  as  it  begins  to  develops 
itself,  are  of  a  purely  nervous  nature,  which  appears  to  justify 
this  assertion.*     However,  in  order  to  prove  its  correctness, 

*  Peter  Courmontagne,  set.  22,  a  private  of  the  first  regiment  of  cuirassiers  of 
the  royal  guards,  when  fourteen  or  fifteen  years  of  age,  had  been  bitten  by  a  mad 
dog  in  the  right  thigh,  where  an  irregular  cicatrix  was  still  perceptible:  the  ani- 
mal had  died  of  the  disease. 

Ever  since  that  period,  Courmontagne  has  never  ceased  to  be  afflicted  with  a 
kind  of  nervous  affection,  accompanied  with  spasms  and  a  transient  aberration 
of  his  mental  faculties,  to  such  a  degree,  that  from  the  time  of  his  entering  the 
military  service,  his  comrades  endeavoured  to  shun  his  society,  and  he  was 
changed  twice  from  the  regiment-  He  was  irascible,  and  became  frequently 
agitated  by  automatic  movements;  in  his  conversation  he  was  observed  to  be 
blustering  and  incoherent.  He  was  meagre;  his  eyes  looked  haggard;  he  was 
frequently  seized  with  vertigo  and  dimness  of  sight;  his  complexion  became 
ruddy,  and  his  pulse  was  almost  always  vibrating  and  hard.  He  has  always 
felt  an  aversion  for  pure  and  clear  water,  for  which  he  never  showed  the  least 
desire,  not  even  under  circumstances,  when  his  fellow  soldiers,  tormented 
as  they  were  by  the  heat  of  the  day,  used  to  regale  themselves  with  it  in  his 
presence.  Yet  would  he  drink  with  more  or  less  avidity  bitter  decoctions, 
or  any  other  dark  and  high  coloured  beverages. 

Such  was  his  condition,  when  on  May  29,  1821,  he  was  brought  to  the  Hos- 
pital of  the  Royal  Guards  for  a  sprain  of  his  right  foot,  contracted  during  the  violent 
exercises  on  horseback.  Soon  after,  symptoms  of  nostalgia  began  to  show  them- 
selves in  conjunction  with  his  general  and  habitual  uneasiness,  and  Courmon- 
tagne declared  loudly  his  wish  to  be  discharged.  With  that  intention,  and  far 
from  allowing  himself  to  be  cured,  he  secretly  employed  a  ligature,  and  an  unfa- 
vourable position  for  the  limb,  in  order  to  stop  the  circulation.  In  consequence 
of  which  a  gangrenous  spot  made  its  appearance  near  the  anterior  part  of  the 
foot,  which  increased  most  rapidly,  and,  finally,  the  entire  member  becoming 
sphacelated  throughout,  rendered  its  amputation  indispensable. 

After  several  paroxysms  of  traumatic  irritation,  which  had  been  momentarily 
augmented  by  digressions  from  the  prescribed  regimen,  the  wound  had  already 


12  Hydrophobia. 

we  will  give  a  summary  account  of  the  experiments  of  the 
celebrated  Rossi,  professor  of  the  university  of  Turin. 

These  experiments  consist  in  making  an  incision  into  some 
fleshy  part  of  a  healthy  and  vigorous  animal,  and  in  enclosing 
within  that  incision  a  portion  of  nerve,  taken  at  the  same  time 

passed  through  all  its  stages,  and  cicatrized  nearly  two-thirds  of  its  size,  when, 
on  the  thirtieth  day  after  the  operation,  the  patient  suddenly  manifested  a  mark- 
ed aversion  for  all  sorts  of  transparent  fluids,  and  evinced  signs  of  an  increase  of 
spasms  and  of  cerebral  inflammation.  He  was  attacked  with  convulsions,  locked 
jaws,  and  grinding  of  the  teeth,  and  actually  fell  into  a  state  of  tetanic  contrac- 
tion. All  excretions  were  suppressed,  the  spasms  and  the  rigidity  assumed  a 
double  intensity,  and  the  soldier  expired  in  the  night  of  the  thirty-second  or 
thirty-third  day. 

As  during  life-time  every  circumstance  had  justified  the  presumption  that  the 
disease  must  have  existed  in  the  brain,  the  autopsy  of  the  body  was  therefore 
commenced  with  that  cavity.  Behold,  then,  the  numerous  derangements  which 
were  there  encountered:  hypertrophia  of  the  cranium,  chiefly  of  the  occipital  re- 
gion; considerable  engorgement  of  the  meningeal  and  cerebral  vessels,  as  well 
as  of  the  superior  longitudinal  sinus  and  plexus  choroïdes;  slight  granulations  at 
the  periphery  of  the  hemispheres;  about  one  ounce  of  a  yellowish  serum  in  the 
lateral  ventricles;  hardness  and  compactness  of  the  substance  of  the  brain 
throughout,  of  the  medulla  oblongata,  and  more  especially  of  the  annular  pro- 
tuberance, in  the  substance  of  which  a  reddish  tint  was  observed,  which  was 
equally  obvious  in  the  thalami  of  the  optic  nerves;  the  neurileme  of  most  all  the 
nerves  of  the  medulla  oblongata,  near  their  origin,  participated  of  that  same  red- 
dish and  inflammatory  complexion. 

The  air  passages  which  we  carefully  examined,  and  the  mucous  membrane  of 
the  alimentary  canal  had  nothing  to  offer  us  for  pathological  observation;  the 
lungs,  with  the  exception  of  some  pretty  old  adhesions,  and  all  the  abdominal 
viscera,  were  found  in  their  natural  condition.  The  liver  alone  had  increased 
somewhat  in  volume,  and  was  in  a  hypertrophic  state.  But  to  our  great  surprise 
we  found  not  the  slightest  vestige  of  inflammation  in  the  pericardium;  it  had 
formed  a  close,  though  doubtless  very  old  adhesion  with  the  entire  periphery  of 
the  heart  or  its  capsular  membrane,  with  which  the  first  mentioned  sero-fibrous 
coat  was  completely  amalgamated.  The  cavities  of  the  heart  were  greatly  con- 
tracted, and  the  principal  vessels  which  derive  their  origin  from  that  organ  had 
nearly  lost  a  third  of  their  diameter. 

The  wound  of  the  stump,  now  almost  entirely  cicatrized,  exhibited  nothing 
uncommon. 

After  this  exposition,  it  is  evident  that  the  symptoms  and  occurrences,  as  they 
appeared  in  the  subject  of  this  notice,  must  have  belonged,  no  doubt,  to  the 
hydrophobic  virus  having  been  inoculated  by  the  bite  of  the  rabid  animal, 
which  died  of  this  disease  a  few  hours  afterwards;  and  it  is,  moreover,  clear  that 
this  virus,  without  occasioning  any  violent  fits,  has  remained  dormant  in  the  sys- 
tem up  to  the  period  when  the  exciting  causes,  of  which  we  have  spoken,  seem- 
ed to  have  developed  its  eflfects.  Every  thing  appears  also  to  prove  that  it  had 
been  concentrated  in  the  cerebral  and  nervous  systems. 


Hydrophobia.  1 3 

from  another  animal  which  had  been  seized  with  madness  and 
one  of  its  most  violent  fits.  At  periods  which  are  fixed  by 
nature,  the  former  becomes  likewise  enraged,  and  dies  of  the 
same  train  of  events. 

There  is  yet  another  difficult  question  to  determine,  whether 
the  hydrophobic  virus  is  susceptible  of  being  communicated 
from  one  individual  to  another  through  the  agency  of  an  ex- 
crementitious  fluid,  or  from  the  mother  to  her  infant  by  means 
of  the  circulation.  The  reasoning  of  v/riters  upon  this  sub- 
ject has  not  as  yet  resulted  in  any  thing  satisfactory,  and  our 
experience  has  not  been  sufficiently  extensive  to  permit  us  to 
decide. 

Of  all  animals,  wolves,  dogs,  and  cats  are  most  subject  to 
hydrophobia;  man  rarely  falls  into  those  fits  which  it  is  apt  to 
occasion,  unless  the  virus  has  been  communicated  to  him.  Its 
predisposing  causes,  with  the  animals  just  mentioned,  would 
seem  to  be  the  heat  of  the  climate,  the  use  of  salted  food, 
great  fatigue  and  thirst;  but,  above  all,  the  amorous  heat  which 
sways  these  animals  for  a  long  time,  and  almost  always  with- 
out taking  food  or  drink. 

The  exciting  causes  are  toothach,  a  swelling  of  the  max- 
illary glands,  brought  on  in  the  usual  way  by  the  sudden  change 
from  heat  to  cold,  or  some  derangement  of  the  organs  of  deglu- 
tition, caused  by  the  presence  of  a  fragment  of  fish-bone, 
or  any  other  piece  of  more  or  less  sharp-pointed  bone,  which 
has  become  fixed  there  and  irritates  these  parts. 

Rabid  dogs  are  more  frequently  met  with  in  hot  than  in 
temperate  climates;  and  if  the  hydrophobia  never,  or  but 
very  rarely,  has  been  observed  in  Egypt,  it  is  to  be  accounted 
for  by  the  peculiar  character  of  the  animals  and  their  habits 
of  life:  through  the  day  they  lie  quiet  in  the  shade,  in  the  wa- 
ter or  close  by  the  vessels  which  are  filled  with  it,  and  which 
the  Egyptians  keep  for  their  use,  and  take  care  to  replenish 
every  day.  They  run  about  only  at  night,  and  evince  the 
symptoms  and  the  effects  of  the  amorous  heat  at  very  distant 
intervals,  and  then  during  a  few  moments  only;  they  are 
seldom  seen  in  the  act  of  coition;  yet  if  there  exist  so  large 
a  number  of  these  animals  in  the  different  parts  of  Egypt, 


14  Hydrophobia. 

it  is  because  none  of  them  are  killed,  and  because  they  live 
altogether  in  the  streets,  without  ever  entering  the  houses. 

The  prognosis  in  hydrophobia  is,  generally  speaking,  most 
melancholy.  For,  as  soon  as  the  symptoms  have  developed 
themselves,  human  art  has  scarcely  any  remedies  at  all  to  offer; 
and  the  man  who  has  become  its  victim,  is  in  some  measure 
condemned  to  perish,  unless  nature,  by  means  of  unforeseen 
circumstances,  should  establish  a  favourable  crisis,  as  in  a  few 
instances  this  has  actually  been  the  case. 

Owing  to  prejudice  and  usage,  various  remedies  have  been 
employed  with  a  view  promptly  to  terminate  the  sufferings 
and  the  life  of  the  unhappy  hydrophobic  patient.  Whilst 
some  have  directed  four  of  his  veins  to  be  opened  at  once, 
others  have  endeavoured  to  suffocate  him;  and  again  others 
have  caused  him  to  be  stung  by  venomous  animals,  such  as  the 
viper,  under  an  impression  that  the  virus  of  this  reptile  must 
neutralize  that  of  madness.  All  these  proceedings,  however, 
opposed  as  they  are  to  the  principles  of  art  and  humanity,  de- 
rive their  origin  from  the  grossest  barbarity,  and  cannot,  un- 
der any  circumstance,  be  employed  again.  If  the  exhibition 
of  suitable  remedies  should  be  impossible,  the  patient  must  be 
abandoned  entirely  to  the  resources  of  nature,  taking  care  only 
to  prevent  his  doing  mischief  to  any  of  his  fellow  beings. 

If  there  be  yet  time,  however,  to  afford  relief  to  persons 
bitten  by  a  rabid  animal,  the  appropriate  remedies  must  be 
employed  in  the  promptest  manner  possible.  The  indication 
which  has  appeared  to  us  the  most  simple,  is  to  prevent  the 
introduction  of  the  venomous  substance  into  the  internal  or- 
gans of  the  body,  and  to  defeat  the  consequences  of  these  con- 
tused and  lacerated  wounds.  In  order  to  effect  this,  the  solu- 
tion of  continuity  must  be  immediately  enlarged,  one  or  more 
cupping-glasses  applied  over  it,  so  as  to  absorb  the  fluids  from 
the  opened  vessels,  which  may  have  become  saturated  with 
the  poison,  and  to  cauterize  it  afterwards  by  employing  either 
the  actual  cautery  or  the  caustic  potash.  It  will  then  be  pru- 
dent to  promote  the  effect  of  these  topical  applications,  by  the 
use  of  such  other  remedies  as  have  met  with  the  most  success; 
for  example,  the  gum  ammoniac  combined  with  some  bitter 


Hydrophobia.  15 

vegetable  infusion;  the  narcotics  and  anti-spasmodics,  such  as 
camphor,  opium  in  substance;  which  should  be  preceded  by 
general  blood-letting  and  scarified  cupping  over  both  sides  of 
the  spine  and  epigastrium,  to  which  parts,  moreover,  daily 
embrocations  of  camphorated  oil  of  chamomile  may  be  applied. 
With  the  aid  of  the  above  remedies,  employed  at  the  very 
threshold,  to  be  sure,  of  an  attack  of  the  hydrophobic  symp- 
toms,  we  have  had  the  good  fortune  to  treat  a  merchant  in 
Paris,  of  thirty-five  or  thirty-six  years  of  age,  and  to  restore' 
him  to  perfect  health.  This  individual,  whom  we  have  re- 
peatedly seen  since  that  occurrence,  is  doing  quite  well,  and 
appears  to  have  completely  regained  his  natural  cheerfulness. 

Mercurial  frictions  have  been  recommended  likewise  with 
some  show  of  reason.  I  have  employed  them  in  several  cases 
as  a  preservative  remedy,  and  have  directed  them  to  be 
applied,  at  intervals  of  from  five  to  six  days,  to  the  soles  of 
the  feet  and  to  the  inside  of  the  legs. 

There  have  been  persons  who,  believing  themselves  to  have 
heew  bitten  by  rabid  animals,  which  indeed  they  had  not, 
have  yet  been  attacked  with  symptoms  of  hydrophobia,  and 
perished  in  consequence.  This  is  easily  understood,  when 
we  consider  the  analogy  which  exists  between  the  conse- 
quences of  a  nervous  affection,  the  result  of  violent  passions  of 
the  mind,  and  those  which  are  caused  by  madness,  and  which 
is  the  same  that  happens  so  frequently  to  over-delicate  and 
irritable  women,  in  consequence  of  their  confinement,  or  hys- 
terical vapours.  We  have  even  seen  tetanus  complicated  with 
the  very  same  nervous  paroxysms,  of  which  we  intend  to  speak 
in  the  article  devoted  to  that  complaint. 

I  moreover  believe,  supposing  that  the  hydrophobic  symp- 
toms had  already  broken  out,  and  supposing  that  the  patient 
could  be  secured  without  inconvenience,  by  covering  his  eyes 
with  a  bandage,  after  having  separated  and  securely  fixed  his 
jaws,  I  believe  it  to  be  possible  that  he  could  be  made  to  swal- 
low liquids  which,  given  in  a  proper  dose,  should  exert  a  seda- 
itive  and  anti-spasmodic  effect.  By  this  means,  the  spasm  and 
;the  irritation  might  possibly  be  overcome,  under  which  the 
nervous  system  of  the  throat  and  all  the  muscular  parts  of  the 


16  Poisoned  Wounds. 

air  and  alimentary  passages  labour,  and  which  is  one  of  the 
principal  causes  of  death.  The  operation  of  these  remedies 
might  next  be  promoted  by  the  application  of  the  actual  cautery 
to  the  injured  parts,  however  much  they  might  have  cicatrized, 
or  to  any  other  spots  distant  from  the  centre  of  vitality.  The 
sudden  and  instantaneous  immersion  of  the  entire  body  of  the 
patient  into  cold  water,  the  application  of  ice  over  the  irritated 
parts,  by  which  the  general  blood-letting  and  the  cupping- 
glasses,  placed  abundantly  over  the  regions  above  designated, 
should  be  preceded;  all  these  means  will  be  very  proper  to 
cause  a  suspension  of  the  terrible  paroxysms  of  this  disease. 
Experience  must  prove  their  efficacy.  They  who  are  engag- 
ed in  making  these  experiments  ought  to  take  the  utmost  pre- 
caution against  receiving  upon  their  mucous  surfaces,  and  es- 
pecially upon  wounds  or  recent  cicatrices,  the  smallest  parti- 
cle of  saliva  which  the  patient  frequently  emits,  for  it  is 
maintained  that  such  an  emission  is  sufficient  to  communicate 
the  hydrophobia. 

Of  Poisoned  Wounds. 

Poisoned  wounds  consist  in  very  small  injuries,  similar  to 
punctures,  which  are  succeeded,  however,  by  an  immediate 
swelling,  not  observed  in  the  first  instance  in  the  other  solu- 
tions of  continuity.  They  differ,  according  to  the  animals 
which  produce  them.  These  animals  are  of  two  kinds,  rep- 
tiles and  insects. 

Among  the  reptiles,  nearly  all  the  snakes  and  serpents  may, 
more  particularly  in  hot  countries,  be  looked  upon  as  veno- 
mous animals.  In  temperate  climates,  there  is,  properly 
speaking,  none  but  the  viper.  Among  the  insects,  the  scor- 
pion, wasp,  bee,  musquito,  &c.  rank  as  such.  Their  sting  is 
decidedly  venomous  to  a  certain  degree,  especially  in  hot  cli- 
mates. Most  of  these  insects  pierce  through  the  skin  with  the 
aid  of  a  short  pointed  trunk,  from  which  a  few  particles  of  a 
peculiar  fluid  ooze,  which  is  more  or  less  acrid  and  capable  of 
irritating  the  parts. 

The  symptoms  which  these  punctures  exhibit,  differ  from 
those  which  accompany  the  bites  of  reptiles.     The  sting  of 


Poisoned  Wounds.  17 

these  insects  announces  itself  forthwith  by  a  troublesome  itch- 
ing sensation;  the  cutaneous  tissue  instantly  becomes  bloated 
within  a  very  small  circle,  and  circumscribed  form;  the  pru- 
ritus continues  to  increase  during  the  first  twenty-four  hours, 
but  finally  terminates  in  a  slightly  inflamed  spot.  Beside 
these  phenomena,  the  sting  of  the  scorpion  is  mostly  attended 
by  a  feeling  of  numbness  in  the  wounded  part,  and  which 
in  some  instances  extends  over  the  entire  structure  of  the 
limb;  the  swelling  spreads  further  of  its  own  accord,  and 
changes  the  colour  of  the  skin  to  a  bluish  appearance. 

These  stings,  when  left  to  themselves,  have,  generally 
speaking,  no  unpleasant  consequences.  The  public  prints, 
however,  have  not  long  since  related  the  account  of  a  postilion 
who,  with  his  horses,  perished  in  consequence  of  the  number- 
less stings  received  from  a  swarm  of  bees,  which  he  met  on 
his  passage  through  a  forest,  during  an  exceedingly  warm 
night  in  summer.  I  have,  likewise,  had  occasion  to  observe 
at  Newfoundland,  that  the  stings  of  the  musquitos  of  that 
climate  produced  upon  the  skin  a  general  emphysema,  follow- 
ed by  some  degree  of  feverish  excitement. 

Among  the  great  number  of  persons  who,  during  our  so- 
journ at  Alexandria,  had  been  stung  by  scorpions,  only  one  in- 
dividual was  seized  with  the  symptoms  which  writers  ascribe 
to  the  sting  of  the  tarantula.  The  spot  of  this  wound  (it  was 
the  middle  finger)  presented  a  slight  swelling;  the  hand  and 
arm  were  benumbed;  the  patient  was  in  a  state  of  the  utmost 
dejection;  he  shed  tears  and  sighed  frequently;  he  had  lost  his 
sleep  and  appetite;  he  experienced  rigors  of  terror,  and  had 
unpleasant  dreams.  The  unexpected  approach  of  several  per- 
sons occasioned  him  some  slight  convulsions.  In  this  condi- 
tion he  had  been  for  forty-eight  hours,  before  I  could  see  him. 
The  application  to  the  finger  of  a  little  volatile  alkali;  the  in- 
ternal use  of  it  to  the  amount  of  eight  drops  in  a  glass  of  the 
infusion  of  chamomile;  exercise,  rides,  and  sea-bathing,  quiet- 
ed all  these  symptoms.  On  the  third  day  this  soldier  returned 
to  his  corps  completely  recovered. 

The  more  efficacious  remedies  for  such  wounds,  are  the  im- 
mediate application  of  some  corrosive  or  highly  tonic  substance, 
C 


18  Poisoned  Wounds. 

and  the  administration  of  cordials  internally.  Amongst  these 
are  ammoniac,  muriate  of  ammonia  dissolved  in  water,  urine, 
vinegar,  muriate  of  soda,  nitric  acid,  or  any  other  analogous 
substance;  the  application  of  a  very  small  piece  of  burning 
charcoal,  a  small  portion  of  clay,  or  a  little  lime  dissolved  in 
water,  or  the  combustion  of  a  few  grains  of  powder  are  suffi- 
cient instantly  to  destroy  their  effects.  And  if  the  sting  has 
occasioned  a  slight  derangement  of  the  system,  a  little  brandy, 
coffee,  or  some  vulnerary  balsam,  will  completely  assist  the 
topical  applications  and  restore  the  patient. 

I  shall  not  dwell  upon  the  effects  of  the  sting  of  the  taran- 
tula and  all  the  other  spiders,  which  in  my  opinion  does  not 
differ  essentially  from  that  of  other  insects.  My  experience 
at  least  has  not  taught  me  anything  more  in  this  respect. 

With  respect  to  the  bites  inflicted  by  reptiles,  the  most  dan- 
gerous are  those  of  the  viper  and  the  rattle-snake,  the  latter  of 
which  announces  its  approach  by  the  sound  of  its  rattles.  This 
kind  of  wound  is  immediately  attended  with  a  most  lively 
pain  and  a  sensation  of  numbness  in  the  part,  which  forthwith 
begins  to  swell.  The  swelling  increases  rapidly  and  becomes 
the  seat  of  bluish  and  gangrenous  vesications.  The  pain  and 
stiffness  spread  from  one  place  to  another,  and  finally  involve 
the  whole  limb.  The  intumescence  extends  over  all  parts  of 
the  body  and  carries  its  principal  effects  into  the  cavity  of  the 
abdomen;  the  liver  becomes  engorged;  the  bile  is  forced  out  of 
its  channels,  re-enters  the  volume  of  the  circulation,  and  is  the 
cause  of  jaundice. 

These  preliminary  symptoms  frighten  the  patient;  he  expe- 
riences headache,  vertigo,  diiïiculty  of  breathing,  syncope; 
the  circulation  becomes  disordered,  the  pulse  is  small,  and  the 
extremities  grow  cold.  Within  the  first  twenty-four  hours 
vomiting  supervenes,  succeeded  by  convulsive  motions  and  a 
burning  heat  in  the  intestines;  the  powers  of  motion  and  feel- 
ing become  gradually  extinct;  the  swelling  increases;  a  lethar- 
gic drowsiness  comes  on,  which  is  only  interrupted  by  con- 
vulsive motions  or  by  raving  madness;  hemorrhages  from  the 
anus,  nose  and  mouth  take  place,  and  the  patient  perishes  on 
the  third  or  fifth  day,  with  all  the  symptoms  of  a  putrid  ma- 


Poisoned  Wounds.  19 

lignant  fever.  If  he  survives  the  third  day,  nature,  by  re- 
newed efforts,  brings  on  a  crisis,  and  may  possibly,  though 
indeed  very  slowly,  shake  off  the  disease.  The  most  favour- 
able and  most  common  sign  of  such  a  crisis  is  a  very  copious 
persjiiration,  which  makes  its  appearance  on  the  third,  fifth, 
or  at  latest,  on  the  seventh  day  from  the  first  attack  of  the 
symptoms,  which,  however,  do  not  always  present  the  same 
degree  of  intensity.  For  instance,  if  the  viper  had  to 
strike  through  coarse  woollen  cloths,  or  if  he  has  previously 
bitten  other  subjects,  his  poison  is  then  less  active,  and  will 
also  be  less  powerful  during  the  colder  seasons,  more  particu- 
larly if  he  is  young  and  had  not  at  all  been  irritated  before. 

It  is  difficult  to  explain  the  modus  operandi  of  this  particu- 
lar poison  in  the  parts  of  the  living  animal,  and  its  agency  in 
the  production  of  all  the  above  phenomena.  Besides,  the 
subtle  qualities  which  it  must  possess,  it  has  doubtless  that  of 
stupefying  the  nervous  principle,  by  determining  a  peculiar 
irritability  to  the  muscular  system,  and  by  diluting  the  fluids 
so  as  to  separate  the  aggregating  particles.  Nature  fortunately 
exerts  herself  continually  to  prevent  the  disorganization  of 
these  fluids. 

In  general,  the  prognosis  in  these  bites  is  most  unfavoura- 
ble; it  varies,  however,  according  to  the  situation  of  the 
wound,  its  depth,  the  nature  of  the  poison,  the  greater  or 
less  agitation  of  the  mind,  the  temperament  of  the  subject, 
the  climate,  &c.  The  gloomy  occurrence  may  upon  this 
occasion  be  remembered,  which  happened  at  Rouen,  to  the 
keeper  of  one  of  these  reptiles  (a  rattle-snake),  imported 
into  France  from  America.  The  effects  of  the  unexpected 
bite,  which  this  animal  inflicted  upon  the  finger  of  the  keeper, 
were  so  rapid,  that  in  spite  of  the  most  strenuous  efforts  made 
by  the  physicians  of  the  district,  the  patient  died  in  the  space 
of  a  few  hours,  after  exhibiting  all  the  symptoms  which  we 
have  enumerated.  Nevertheless,  we  venture  to  believe,  that 
if  immediately  after  the  bite  he  had  received  the  assistance 
which  we  shall  mention  below,  the  fatal  operation  of  that  poi- 
sonous contagion  might  have  been  arrested. 

The  indication  presented  by  these  solutions  of  continuity,  is 


20  Gun-sliot  Wounds. 

to  neutralize  the  virus,  either  by  causing  it  to  be  absorbed,  or 
by  sucking  it  out,  by  which  its  diffusion  and  passage  into  the 
animal  economy  will,  of  course,  be  prevented.  The  method 
to  be  employed  for  its  fulfilment,  consists  in  making  incisions 
of  various  kinds,  if  necessary,  and  cauterizing  them  m^-e  or 
less  actively;  but  the  most  efficacious  method  in  our  opinion, 
and  which,  in  my  lessons  on  clinical  surgery,  I  have  demon- 
strated, long  before  Doctor  Barry  in  his  memoirs  had  spoken 
of  it,  consists  in  ihe  forcible  and  repeated  application  of  the 
piston-cups  as  often  as  the  depth  of  the  wound  may  require  it. 
In  all  other  respects  the  treatment  is  to  be  conducted  on  the 
same  plan  as  that  of  a  wound  caused  by  some  rabid  animal. 

Of  Gun-shot  Wounds. 

The  study  and  the  investigation  of  gun-shot  wounds  pre- 
sents to  the  young  practitioner,  desirous  to  inform  himself,  a 
long  series  of  fortunate  occurrences  which  astonish  him,  and 
a  mass  of  dreadful  accidents  which  frighten  him.  Not  unlike 
the  thunderbolts  of  heaven,  the  instruments  of  war  also  per- 
form their  miracles;  they  wound  the  parts  of  the  body,  and  in 
the  midst  of  their  substance  work  injuries,  the  extent  of  which 
the  man  of  science  would  not  always  be  capable  of  ascertaining, 
vv^ere  it  not  for  the  circuitous  routes  which  the  balls  are  com- 
pelled to  make  in  their  passage  through  the  living  and  more  or 
less  elastic  tissues.  These  projectiles  lacerate  the  soft  parts, 
shatter  the  bones,  penetrate  into  the  cavities,  and,  to  a  certain 
extent,  disorganize  the  viscera  which  support  life.  It  is  difficult, 
therefore,  to  give  a  short  and  accurate  definition  of  this  kind  of 
solution  of  continuity,  owing  to  the  different  phenomena 
which  these  injuries  exhibit. 

The  causes  which  produce  them  are  bodies  joropelled  by 
gun  powder  from  engines  of  an  infinite  variety  of  construction 
and  names,  which  are  destined  to  throw  bombs,  howitzers, 
bullets,  balls  or  shot.  All  the  bodies  thrown  in  this  manner 
travel,  in  general,  with  exceeding  rapidity,  and  reach  their 
destination  nearly  as  soon  as  the  light,  and  far  more  expedi- 
tiously than  the  sound,  so  that  the  shot  is  received  before  the  ex- 
plosion is  heard.     The  power  of  motion  and  the  celerity  of  the 


Gun-shot  Wounds.  21 

bodies  are  in  proportion  to  the  engines  which  propel  them. 
Their  direction  is  sucli  that  the  diagonal  drawn  from  the  point 
of  departure  to  the  point  of  their  fall,  and  the  parabola  which 
they  describe,  are  so  much  the  greater  in  proportion  to  the  ex- 
tent of  the  space  over  which  they  travel.  This  phenomenon 
is  owing  to  two  principal  causes-,  first,  on  account  of  the  resis- 
tance which  the  ball  meets  with  on  the  part  of  the  air;  and, 
secondly,  on  account  of  the  earth's  power  of  attraction.  Fluid 
masses  exert  that  resistance  even  to  a  higher  degree  than  the 
atmospheric  air.  Spheric  or  rounded  bodies,  such  as  ball  and 
bullet,  at  the  end  of  their  course  revolve  upon  themselves,  or, 
in  other  words,  upon  their  axis,  and  can  for  some  time  keep 
themselves  in  their  curvilinear  motion.  The  consequence  of 
which  is,  that  as  soon  as  they  meet  at  this  distance  any  body 
of  equal  form,  they  pass  nearly  over  its  entire  periphery,  and 
of  course  must  produce  eifects  different  from  those  which  take 
place  when  they  encounter  it  at  the  very  outset  of  their  ca- 
reer, and  in  their  original  direction. 

Bombs,  howitzers,  and  grenades,  are  spherical  bodies  of  iron, 
hollow  inside,  and  filled  with  powder,  the  explosion  of  which 
bursts  their  parietes,  and  reduces  them  to  pieces,  difiering  in 
shape  and  size,  and  presenting,  most  always,  irregular  cutting 
edges  with  angles  of  more  or  less  sharpness.  The  balls  are  of 
two  kinds,  either  two  and  two  united  by  a  bar  of  the  same 
metal,  which  has  procured  for  them  the  name  of  bar-shot 
(boulets  rames),  and  are  employed  in  the  naval  service;  or  sim- 
ple spherical  bodies,  entire  in  their  circumference.  The  balls 
are  also  of  different  calibres,  varying  in  weight  from  half  a 
pound  to  forty-eight  and  upwards.  This  number  is  even  with 
some  nations,  uneven  with  others.  The  bullets  are  likewise 
of  different  calibres;  the  largest  bear  the  name  of  biscaians, 
and  are  commonly  made  of  iron.  The  musket  and  pistol 
balls  are  made  of  lead.  Amongst  all  European  nations  they 
are  plain  and  uniform;  but  the  Mamelucks  and  the  Arabians, 
as  I  have  had  opportunity  to  observe,  force  an  iron  wire, 
of  more  or  less  thickness,  through  them,  which  converts  them 
into  chain-shot,  or  they  leave  attached  to  them  the  pedicle 
which   they  have  acquired  in  the  bullet-mould.     It  is  wor- 


22 


Gun-shot  Wounds. 


thy  of  remark,  that  with  a  view  doubtless  to  economize  that 
metallic  substance,  or  in  order  to  render  these  bullets  still  more 
destructive,  they  combine  with  the  lead  divers  other  hodies, 
such  as  stones,  iron  or  copper,  which,  as  I  have  frequently 
noticed,  have  a  tendency  to  separate  in  our  parts.  Several  of 
them  I  have  found  surrounded  with  a  glutinous  substance,  with 
which  it  is  likely  they  had  combined  corrosive  materials  which 
I  have  not  been  able  to  distinguish.  These  substances  disap- 
pear as  soon  as  they  are  discharged  from  the  canon's  mouth, 
and  cannot  in  any  way  change  the  nature  of  these  projectiles. 

Such  foreign  bodies  may  carry  before  or  after  them  other 
substances,  different  in  shape  and  character,  such  as  portions 
of  clothes,  leather,  armour,  some  piece  of  money,  wad,  &c. 
When  they  are  driven  with  force  and  strike  our  parts  in  their 
original  direction  at  no  great  distance  from  the  point  of  their 
departure,  they  perforate  them,  lacerate  them,  and  carry  them 
off  in  part  or  entirely.  If,  on  the  contrary,  they  are  near  the 
termination  of  their  career,  they  revolve  upon  their  own  rotund 
surface  without  changing  the  extremely  elastic  tegumentous  or 
membranous  coverings,  which  yield  to  their  impulse,  while  the 
subjacent  compact  or  fragile  parts  are  ruptured,  lacerated  or 
broken.  To  these  circumstances  must  the  cause  of  so  many  sud- 
den deaths  be  referred,  which  for  so  long  a  time  have  been  attri- 
buted to  the  pressure  of  the  air  upon  the  sensible  parts,  thus 
forcibly  displaced  and  agitated  by  the  ball.  It  is  sufficient  to 
read,  the  memoir  of  Levacher,  printed  in  the  Transactions  of  the 
Ancient  Royal  Academy  of  Surgery,  in  order  to  be  convinced 
of  this  mistake,  without  necessarily  appealing  to  experience, 
the  results  of  which  are  already  too  well  known. 

In  the  first  case,  and  supposing  it  to  be  a  ball  of  large  cali- 
bre, which  has  occasioned  the  solution  of  continuity,  it  will 
carry  away  and  unequally  cut  off  the  limb.  .  If  it  strikes  only 
the  fleshy  part  of  its  thickness,  this  alone  is  torn  off,  leaving 
the  bones  denuded.  Sometimes  the  strong  resistance,  made 
by  these  bones,  prevents  the  complete  section  of  the  soft  parts, 
and  the  separation  of  the  limb.  In  that  case  these  parts  are 
extensively  bruised  and  mangled.  But  supposing  it  to  be  a  ball 
of  whatsoever  calibre,  which  at  the  commencement  of  its  career 


Gun-shot  Wounds.  23 

and  with  all  its  original  force  strikes  the  centre  or  the  thickness 
of  a  member,  it  passes  through  by  the  shortest  route,  provid- 
ed that  it  shall  not  meet  with  any  obstacles  which  turn  it  off 
from  its  direction.  The  entry  of  this  ball  is  much  smaller 
than  its  volume;  its  margins  being  slightly  inverted  or  de- 
pressed inwards.  The  lips  of  the  wound  which  are  made  by 
its  outward  passage,  are,  on  the  contrary,  everted,  jaggy,  and 
more  freely  separated,  which  give  them  a  larger  diameter 
than  that  of  the  lips  of  the  wound  made  by  its  entry.  As 
soon,  however,  as  it  meets  with  any.  obstacles  in  its  way,  the 
ball  changes  both  its  form  and  direction,  and  makes  several 
turnings  and  windings,  in  such  a  manner  that  it  may  strike 
some  more  or  less  distant  point  from  its  entrance,  and  become 
lodged  in  either  the  most  elevated  or  the  most  oblique  part  of 
the  limb,  so  as  to  run  over  several  regions.  Its  career  is  usu- 
ally arrested  at  the  articulations,  at  the  attachments  of  the  ten- 
dons, the  aponeuroses,  or  by  any  bony  protuberances.  In 
general,  it  follows  the  course  of  the  nerves  and  blood-vessels. 
It  may  separate  also  into  several  fragments  which  become  suc- 
cessively loosened  one  by  one,  and  take  different  routes.  As 
soon  as  the  balls  have  reached  the  end  of  their  career,  they 
operate  upon  our  parts  in  the  same  manner  as  bullets,  and  on 
a  smaller  scale  produce  the  same  results. 

The  bursting  of  bombs,  of  howitzers,  or  the  fragments  of 
stones  thrown  by  pedereros,  pursue  nearly  the  same  direction, 
but  give  rise  to  modifications,  according  to  the  nature  and 
shape  of  the  injuries  which  they  produce.  They  are  less  cir- 
cumscribedj  the  parts  are  less  disorganized,  and  of  a  less  black- 
ish appearance;  they  are,  moreover,  almost  always  accompa- 
nied by  hemorrhage,  and  in  their  shape  resemble  generally 
the  wounds  caused  by  cutting  instruments. 

The  temperature  of  missiles  thrown  by  gunpowder  is  never 
changed  like  that  of  the  bursting  of  bombs  and  howitzers, 
which,  between  two  different  times,  are  found  to  be  in  contact 
with  fire.  The  pathological  observations  and  the  experience 
made  upon  that  subject,  place  it  now-a-days  beyond  all  doubt 
that  these  bodies  do  not  cauterize,  as  it  has  been  believed  by 
older  writers.     Our  own  illustrious  Ambrose  Paré  has  this 


24  Gun-shot  Wounds, 

subject  sufficiently  explained,  so  that  I  shall  forbear  dwelling 
upon  it. 

The  friction  which  the  projectiles  experience  within  the 
tube  of  the  weapon  which  has  thrown  them,  as  well  as  that  to 
which  they  are  liable  from  the  action  of  the  air  or  other  bodies 
which  they  meet,  before  coming  in  contact  with  our  parts, 
equally  destroys  the  various  substances  which  could  have  been 
applied  to  their  exterior,  and  which  might  have  carried  with 
them  any.  poisonous  principles.  Supposing  even  that  these 
could  have  been  combined  with  the  metals  at  the  moment 
of  the  process  of  casting,  all  that  is  found  liberated  is  after- 
wards volatilized,  and  the  remainder  would  become  identified 
with  the  component  molecules  of  these  metals  in  such  a  man- 
ner as  to  lose  its  power  of  acting  upon  our  organs.  There  is 
consequently  no  cause  for  apprehension  that  the  various  pro- 
jectiles which  may  be  employed  should  be  capable  of  causing 
the  effects  of  poison. 

We  shall  now  proceed  to  the  description  of  the  general  and 
local  phenomena  which  these  foreign  bodies  produce  upon  the 
parts  struck  by  them;  after  which  our  attention  shall  be  direct- 
ed to  the  numerous  and  manifold  symptoms  which  may  be  the 
result  of  the  solutions  of  continuity  which  they  induce. 

It  is,  generally  speaking,  natural  to  believe,  that  the  irrita- 
tion and  the  degree  of  stupor  which  take  place  after  a  gun-shot 
wound,  should  be  in  a  ratio  with  the  force  of  the  body  inflict- 
ing the  wound,  and  that,  consequently,  this  stupor  should  be  in 
proportion  to  the  amount  of  activity  with  which  the  projectile 
body  may  have  been  endowed  by  the  peculiar  structure  of  the 
weapon,  and  the  form  of  the  body  which  may  have  been 
thrown  from  it.  It  is  not  less  reasonable  to  believe  that  the 
greater  the  resistance  is  which  the  injured  parts  may  have  op- 
posed to  the  impelling  force  of  this  body,  the  more  serious  will 
be  the  symptoms.  We  have,  therefore,  to  consider  these 
symptoms  first  in  relation  to  the  local  effects  produced  by  pro- 
jectiles, as  well  as  to  those  which  they  induce  upon  the  sur- 
rounding parts;  and  secondly,  in  relation  to  the  greater  or 
less  degree  of  injury  which  they  frequently  inflict  upon  the 
integrity  of  vital  organs. 


Complication  of  Wounds — Ecchymosis .  25 

The  phenomena  which  are  restricted  to  the  organs  origin- 
ally injured,  are  the  lesion  of  the  integuments,  muscles,  and 
blood-vessels;  the  more  or  less  extensive  laceration  and  attri- 
tion of  the  soft  parts  to  a  proportionate  length,  and  in  a  form 
analogous  to  that  of  the  projectile  itself,  and  presenting,  more- 
over,  a  blackish  eschar  of  a  thickness  proportionate  to  the 
force  of  action  of  the  ofifending  body.     This  eschar  presents 
the  same  phenomena  as  a  burn  or  the  actual  cautery,  although 
there  is,  as  we  have  already  remarked,   nothing  of  a  caustic 
nature  in  the  projectiles  propelled  by  gunpowder.     The  sur- 
rounding or  subjacent  parts  of  the  wound  which  have  escaped 
the  immediate  contact  of  the  body  in  motion,  begin  to  swell 
and  become  engorged,  the  extremities  of  the  rupfured  blood- 
vessels curl  up  and  retract  upon  themselves  in  such  a  manner 
that  there  is  but  very  little  or  no  hemorrhage,   at  any  rate, 
not  in   the  first  moments  after  the  accident;  it  may,  how- 
ever, occur,  even  to  a  fatal  extent,  if  some  large  vessels  have 
not  been  completely  ruptured,  that  is  to  say,  if  the  continuity 
has  been  preserved  in  some  parts  of  their  coats.     Hemorrha- 
ges of  this  character,  in  a  very  few  hours  or  minutes,  destroy 
a  great  number  of  soldiers  left  on  the  field  of  battle,  after  hav- 
ing received  wounds  which  are  combined  with  loss  of  substance 
in  the  soft  parts  and  with  extensive  laceration.  * 

Nervous  cords  are  torn,  tendons  or  aponeuroses  are  lace- 
rated and  occasionally  pulled  from  their  attachments  to  their 
motor  fibres,  or  to  the  bones  themselves;  the  latter  will  be 
fractured  or  shattered  to  pieces,  the  articulations  are  injured  or 
laid  open  with  or  without  destruction  of  substance;  all  these 
are  circumstances  which  present  as  many  varieties  or  particu- 
lar complications  upon  which  we  propose  successively  to  dwell. 

Of  the  Complication  of  Wounds.      Of  Ecchymosis. 
An  ecchymosis  is  the  infiltration  or  effusion  of  bloody  fluids 

*  In  establishing  tiie  flying  ambulances,  the  principal  object  I  had  in  view  was 
in  the  promptest  possible  manner  to  procure  for  those  grievously  wounded  sol- 
diers not  only  the  necessary  assistance  to  prevent  the  fatal  effects  of  these  he- 
morrhages, but  also  the  means  of  their  being  taken  up  and  carried  afterwards  to 
the  ambulances  of  the  first  line,  where  the  important  operations  were  pertormed. 

D 


26  Ecchi/mosis.  —  Traumatic  Fever. 

into  the  cellular  and  dermoid  tissue,  or  between  this  membrane 
and  the  epidermis.  It  takes  place  in  consequence  of  some 
ruptured  blood-vessel,  more  or  less  deeply  situated,  of  either 
the  arterial  or  venous  system;  but  more  frequently  the  latter 
circulating  system,  by  means  of  its  injection  and  some  kind  of 
absorption,  spreads  this  ecchymosis  to  more  or  less  remote 
distances.  These  aberrations  in  the  circulation  of  the  sangui- 
neous fluids  are  characterized  by  a  deeper  or  lighter  shade  of 
a  blackish  or  marbled  aspect  of  the  skin,  by  the  absence  or 
diminution  of  the  latent  heat,  by  intumescence  of  the  parts, 
and  by  the  more  or  less  decided  loss  of  sensibility.  They  are 
more  distinct,  and  far  more  readily  developed  underneath  any 
such  portions  of  the  dermoid  membrane,  the  texture  of  which  is 
loose  and  very  thin,  such  as  the  skin  of  the  eyelids  and  face, 
the  integuments  of  the  organs  of  generation,  &c. 

There  are  circumstances,  when  there  is  no  ecchymosis, 
though  the  contusion  be  violent  and  extensive;  this  hap- 
pens when  the  blood-vessels  which,  from  the  interior  or- 
gans run  towards  the  skin,  have  been  ruptured  beneath  that 
covering,  whereby  the  circulation  is  stopped;  the  same  occurs 
frequently,  after  contusions  of  the  limbs  or  the  trunk  caused  by 
a  bullet,  after  it  has  arrived  at  the  termination  of  its  career. 
(This  will  be  noticed  in  its  place.) 

The  enlargement  of  the  wounds  which  are  attended  by  ec- 
chymosis is  sometimes  sufficient  to  disperse  this  symptom,  the 
entire  removal  of  which  may  subsequently  be  accomplished 
by  compression  and  the  employment  of  repellent  applications. 
Where,  ho-wever,  an  ecchymosis  should  not  be  accompanied 
by  an  external  solution  of  continuity,  scarified  cups,  which 
draw  off  the  extra  vasated  fluid  and  promptly  disgorge  the  ecchy- 
mosed  parts,  must  be  resorted  to,  which,  in  like  manner,  may 
be  followed  up  by  compression  and  the  use  of  any  such  sub- 
stances as  are  calculated  to  promote  resolution. 

Of  Traumatic  Fever. 

If  the  local  symptoms  are  intense,  which  depends  upon  the 
nature  of  the  injured  parts  and  the  extent  of  the  wound,  a 
traumatic  fever  will  not  fail   to  become  developed;  the  irri- 


Injuries  of  the  Nerves.  27 

tation  spreads  gradually  further,  and  concentrates  its  efi'ects 
upon  the  internal  organs  which  are  already  predisposed  to  in- 
flammation and  engorgement,  after  the  shock  and  disturbance 
which  they  have  received  at  the  moment  of  the  injury;  and 
these  organs  are  principally  the  liver,  the  lungs,  and  the  brain. 
Their  functions  are  disturbed  or  suspended,  and  after  some 
degree  of  stupor,  during  which  there  is  a  stagnation  of  the 
fluids  which  pass  through  the  organic  vessels  of  these  viscera, 
a  reaction  supervenes,  and  along  with  it  the  whole  train  of 
traumatic  fever  which  is  ushered  in  by  nervous  agitation  and 
slight  shivering,  small  pulse,  great  anxiety,  suppression  of  all 
the  mucous  secretions,  as  well  as  of  the  process  of  suppuration 
in  the  wound  which  now  assumes  an  unfavourable  aspect. 
These  precursory  symptoms  may  in  like  manner  prove  to  be 
sometimes  the  forerunners  of  the  hospital  gangrene,  sometimes 
those  of  gangrene. 

To  these  first  symptoms  succeed,  immediately  afterwards, 
heat,  an  increase  of  pulse,  burning  thirst,  dryness  of  the  skin, 
redness  and  sympathetic  pains  felt  in  different  parts  of  the 
body,  according  to  the  morbid  predisposition  of  the  organs. 
In  this  way  may  we  account  for  the  formation  of  abscesses  of 
the  liver,  the  phlegmasia  of  the  lungs,  the  serous  or  puru- 
lent effusions  within  the  chest,  subsequent  disorders  which, 
after  being  converted  into  primary  diseases,  may  occasion  the 
death  of  the  subject,  although  the  symptoms  have  originated 
with  the  wound.  I 

The  original  symptoms  produce  difîérent  results.  Exces- 
sive hemorrhages  will  cause  the  death  of  the  wounded  with 
more  or  less  expedition;  or  if  not  overcome  by  them  immedi- 
ately, they  throw  them  into  an  adynamic  state,  the  fatal  con- 
sequences of  which  are  prevented  with  great  difficulty. 

Injuries  of  the  Nerves. 

The  laceration  of  the  nerves  almost  invariably  induces  ner- 
vous digorders,  which  are  confined  to  the  injured  portions,  or 
are  communicated  to  the  whole  system  as  far  as  the  spinal  mar- 
ow  exclusive;  for  it  is  a  rare  event  to  see  this  irritation  extend 
itself  to  the  nain.     These  nervous  disorders  are  distinguished 


28  Foreign  Bodies. 

by  more  or  less  intense  pain,  according  to  the  particular  nature 
of  the  injured  nervous  cords.  The  painful  sensation  occasioned 
by  the  lesion  of  the  nerves  of  relation  is  infinitely  more  quick 
and  acute  than  that  which  results  from  the  lesion  of  nerves  of 
organic  life.  This  latter  pain  is  accompanied  with  a  feeling  of 
local  chilliness  and  painful  anxiety.  In  such  cases  the  increase 
of  sensibility  renders  the  wound  susceptible  of  hospital  gan- 
grene, which  is  to  be  well  distinguished  from  gangrene,  whose 
cause  is,  on  the  contrary,  the  complete  attrition  of  the  tissues. 
The  forcible  separation  of  the  tendons  or  of  fleshy  masses 
is  attended  by  very  great  contraction,  by  effusion  of  the  fluids 
within  the  lamellated  texture  or  the  interstices  of  the  muscles, 
by  an  inflammatory  engorgement,  by  erethismus  frequently  and 
sphacelus.  We  shall  have  occasion  to  speak  of  all  these  com- 
plications- 

Of  Foreign  Bodies. 

Gun-shot  wounds  are  finally  complicated  by  the  presence, 
in  the  living  tissues,  of  the  foreign  bodies  which  did  produce 
them.  These  bodies  vary  indefinitely  in  their  form,  nature, 
size,  and  in  their  manner  of  being  lodged  with  the  parts  upon 
which  they  rest,  or  with  which  they  are  in  contact.  Their 
search  is  an  extremely  delicate  matter  which  we  can  only  be 
so  far  justified  to  undertake  as  it  may  not  prove  injurious  to 
the  integrity  of  the  parts  or  the  organic  functions.  If  in  the 
first  moments  they  cannot  be  extracted  with  ease  and  without 
any  more  serious  inconvenience,  it  must  be  left  to  nature  to 
point  out  to  art  the  best  method  to  be  pursued  of  facilitating 
their  extraction. 

In  all  cases  it  is  proper  to  attempt  to  search  for  these  extrane- 
ous bodies  (projectiles  for  instance)  in  the  shortest  and  least  dan- 
gerous way.  For  that  purpose  it  will  be  necessary  to  enlarge 
the  orifice  of  the  wounds  which  allow  their  passage,  or  rather 
to  make  counter-openings  if  practicable,  in  order  to  extract 
them  with  greater  ease.  Such  as  have  become  embedded  into 
the  bones  or  within  their  interstices  cannot,  unless  they  are 
very  superficial,  be  extracted  without  great  inconvenience  by 
means  of  such  mechanical  instruments,  as  the  more  or  less 


Foreign  Bodies.  29 

complicated  bullet  screws  of  the  ancients,  or  the  rather  more 
perfect  ones  of  the  modern  practice,  and  this  from  two  princi- 
pal reasons: 

1.  If  the  bullet  has  become  wedged  into  the  bones,  it  is 
difficult,  if  not  impossible  altogether,  to  insinuate  the  blades 
of  this  instrument  between  the  bones  and  the  projectile,  with- 
out cutting  off  those  portions  which  are  in  contact  with  them, 
and  tearing  them  off  violently,  proceedings  always  hurtful  and 
more  or  less  dangerous;  therefore  I  hold  that  all  these  instru- 
ments, however  ingeniously  contrived,  are  useless.  On  the 
contrary,  it  is  much  better  to  permit  nature  to  pursue  her  own 
course  of  outlet,  and  to  wait  until  she  has  detached  the  em- 
bedded projectile  and  brought  it  beneath  the  integuments,  or 
within  the  periphery  of  the  bodj^,  from  whence  its  subsequent 
extraction  will  be  equally  expeditious  and  easy. 

2.  In  those  cases,  however,  where  foreign  bodies  are  acces- 
sible to  the  action  of  the  bullet-screws,  and  besides,  sufficiently 
loose  to  be  extracted  without  difficulty,  it  will  always  be  more 
advantageous  to  use  a  simple  dressing — or  polypus  forceps. 

The  fragments  of  arrows  or  javelins  buried  in  the  parts  of 
the  wounded  at  a  greater  or  less  depth,  must  be  extracted 
with  great  precaution,  so  as  not  to  increase  thereby  the  lace- 
ration already  existing;  and  as  the  darts  of  these  arms  have  a 
more  or  less  angular  base,  they  must  not  be  suffered  to  pass 
out  the  same  way  by  which  they  entered.  They  should 
be  extracted,  as  far  as  it  is  possible,  on  the  side  opposite  to 
their  entrance,  and  in  the  direction  of  the  point  of  these  wea- 
pons, by  making  for  this  purpose  such  incisions  as  shall  be 
calculated  to  isolate  them  and  lay  them  bare.  After  which 
they  should  be  immediately  taken  away  with  a  pair  of  forceps 
or  a  suitable  tenaculum;  and  their  extraction  is  the  more  easily 
accomplished  as  they  are  not  embedded  into  the  bones,  and  as 
the  shaft  of  these  weapons,  if  they  should  have  one,  could 
previously  be  cut  off  either  with  a  saw  or  a  cutting  forceps 
(tenaille  incisive).  I  have  had  occasion  to  dress  several  sol- 
diers of  the  ex-guards,  who  had  been  wounded  in  the  battle  of 
Eylau  by  the  arrows  of  the  Calmucs,  in  which  instances  we 
have  put  the  above  principles  into  practice. 


30  Foreign  Bodies. 

As  regards  penetrating  wounds  which  may  be  complicated 
by  the  presence  of  extraneous  bodies,  in  as  much  as  they  pre- 
sent as  many  particular  indications  as  these  bodies  present 
varieties  of  situation,  substance  and  form,  we  shall  be  en- 
abled to  do  justice  to  all  these  considerations  in  each  para- 
graph devoted  to  these  wounds. 

In  order  to  conclude  our  remarks  on  the  complication 
with  which  we  have  been  occupied,  it  remains  yet  to  speak  of 
the  curious  effects  which  sometimes  supervene  at  the  instance 
of  the  presence  or  absence  of  the  projectiles  or  fragments  of 
projectiles  buried  within  our  parts.  Every  army-surgeon,  for 
example,  knows  very  well  that  a  simple  wound  of  a  limb  oc- 
casioned by  a  shot,  does  not  always  amount  to  proof  positive 
that  the  bullet  remains  within  the  substance  of  the  parts.  He 
knows  likewise  that  several  different  causes  may  determine  it 
to  come  out  again  by  the  same  way,  whatever  may  be  its  ex- 
tent or  direction;  but  authors,  unacquainted  with  the  nature 
of  these  causes  and  their  modus  operandi,  do  not  give  any  ex- 
planation of  this  subject,  and  do  not  by  any  means  agree  in 
the  views  which  they  take  of  it.  Some  have  thought  that 
the  bullet,  after  having  penetrated  deeply  into  the  thickness 
of  a  limb,  can  rebound  outwards,  after  it  has  skipped  over 
tendons,  aponeuroses  and  bones.  Others  have  come  to  the 
conclusion  that  the  muscular  contraction  was  frequently  suf- 
ficient to  repel  a  projectile  and  force  it  out  again.  The  ani- 
mal economy  as  well  as  experience  abundantly  demonstrate 
the  error  of  these  opinions,  whilst  we  shall  endeavour  to  re- 
mind the  young  practitioner  that — 

1.  The  lead,  being  nearly  destitute  of  all  elasticity,  is  no 
ways  capable  of  rebounding  from  the  parts  which  it  strikes, 
whatever  may  be  their  density  and  however  feeble  may  be 
the  stroke  of  the  projectile  against  the  parts.  The  bullet 
becomes  entirely  or  partially  flattened,  is  cut  in  two  or  more 
pieces,  and  is  as  plastic  as  the  density  of  the  obstacles  which 
it  breaks  through  will  admit  of  ;  meanwhile  the  parts  which 
have  been  struck  by  it  undergo  in  their  turn  a  corresponding 
alteration.  If  these  consist  of  solid  masses,  they  are  perforat- 
ed, notched,  fractured  or  shattered  to  pieces;  the  bullet  or  its 


Foreign  Bodies.  SI 

fragments  bury  themselves  in  the  substance  of  the  splinters,  in 
the  spongy  part  of  the  bones,  or  in  the  medullary  cavity. 
2.  The  motor  fibre  struck  by  the  bullet  is  instantly  benumbed 
and  deprived  of  its  power  of  contraction;  at  other  times,  how- 
ever trfling  the  shock  may  be,  this  fibre  is  contused,  lacerated, 
and  the  bullet  becomes  lost  in  the  substance  of  the  muscle,  or 
turns  but  very  little  out  of  its  direction,  and  even  if  it  should 
make  a  few  more  or  less  remote  windings,  it  will  only  be  owing 
to  the  little  resistance  which  it  meets  with  in  the  cellular  tis- 
sue, accompanying  the  blood-vessels  or  nerves. 

How  then  can  we  explain  this  repulsion  which  the  bullet 
experiences,  so  that  after  having  more  or  less  deeply  pene- 
trated, it  passes  out  again  by  that  wound  which  by  entering 
it  inflicted? 

Be  the  depth  of  the  passage  which  this  projectile  shall  have 
made  into  the  soft  parts,  ever  so  short,  it  will  not  pass  out  again 
by  the  same  route,  unless  (as  Ambrose  Paré  has  judiciously  ob- 
served) it  be  drawn  or  dragged  out  by  some  portions  of  cloth- 
ing which  have  been  pushed  and  introduced  before  it  into  the 
parts.  It  frequently  happens,  indeed,  when  the  passage  is 
short  that  the  cartridge  in  which  the  bullet  is  enclosed,  is  car- 
ried outwards  by  the  change  of  position  or  the  movements  of 
the  wounded,  in  such  a  manner  that  this  foreign  body,  after 
having  made  its  way  into  the  flesh,  falls  to  the  ground  or  stays 
in  the  habiliments  of  the  individual.  In  the  supposition,  on  the 
contrary,  where  this  passage  is  somewhat  longer,  that  the  open- 
ing of  the  integuments  retracts  by  virtue  of  their  organic  con- 
tractility, and  allows  the  return  of  the  bullet  by  the  same  route 
no  longer,  it  becomes,  then,  necessary  to  enlarge  the  wounds 
and  search  after  it,  for  the  purpose  of  extraction.  Experience 
corroborates  this  opinion,  and  as  we  have  surprized  nature  in 
the  act,  we  propose  to  give  a  true  and  exact  account  of  what  she 
has  presented  us  with  in  the  individual  subjects  of  the  follow- 
ing observations. 

First  Observation.  A  grenadier  of  the  imperial  ex-guards, 
in  a  skirmish  which  took  place  the  day  previous  to  the  battle  of 
Craone,  in  1814,  received  a  gun-shot  wound  in  his  left  thigh. 
This  soldier  presented  himself  at  the  field  hospital  (ambulance). 


32  Foreign  Bodies. 

in  order  to  have  his  wound  dressed;  he  walked  with  his  body 
crooked,  the  affected  thigh  and  leg  bent,  and  he  suffered  some 
extremely  painful  twitches  at  tlie  centre  of  the  wound  with- 
out being  able  to  assign  the  true  cause.      Upon  examination 
it  was  found  that  a  portion   of  his  shirt  had    become  deeply 
entangled  in  a  round  and  scarcely  perceptible  wound,  situated 
on  the  inner  and  superior  side  of  the  left  thigh.     It  appeared 
to  have  insinuated  itself  far  into  the  cellular  texture  which  sepa- 
rates the  tendons  of  the  triceps  adductor,  the  sartorius  muscle, 
and  towards  the  little  trochanter.     I  concluded  at  once  that  this 
piece  of  shirt  had  been  pushed  by  the  bullet  into  the  substance 
of  the  thigh.     In  order  to  overcome  the  resistance  of  the 
closed  orifice  of  the  wound  of  the  integuments  and  aponeuroses 
which  had  made  way  i'or  this  twofold  foreign  body,  I  accord- 
ingly enlarged,  with  the  aid  of  a  blunt-pointed  straight  bistoury, 
the  two  superior  and  inferior  angles  of  the  wound,  and  after 
pulling  a  little,  I  succeeded  in  extracting  this  shred  of  folded 
shirt,  at  the  bottom  of  which  there  was  enclosed  a  bullet  of 
heavy  caliber  and  a  piece  of  the  material  of  his  pantaloons. 
This  projectile  was  flattened  and   one  of  its  sides  somewhat 
jaggy,  which  induced  the  belief  that  in  its  passage  it  must  have 
encountered  the  apex  of  the  little  trochanter.     In  fact,  the  fe- 
male catheter,  introduced  into  the  wound  after  the  extraction  of 
the  extraneous  substance,  sunk  beyond  that  eminence  towards 
the  linea  aspera  of  the  femur.     The  wound  which  was  after- 
wards treated  as  a  simple  wound,  got  well  in  a  few  weeks. 

Second  Observation.  In  the  disastrous  battle  of  Mont- 
Saint-Jean  (Waterloo),  1815,  a  young  soldier  of  the  line  receiv- 
ed a  shot  during  an  attack  upon  one  of  the  enemy's  positions. 
The  bullet  which  had  been  thrown  from  a  height,  after  passing 
over  the  waistband  of  the  breeches,  had  penetrated  a  little 
above  the  spermatic  vessels  of  the  right  side,  and  pushing  be- 
fore it  a  piece  of  shirt,  it  had  travelled  under  the  skin  and  over 
the  passage  of  the  cord,  till  within  the  scrotum  on  the  external 
side  of  the  testicle,  in  such  a  manner  that  the  shirt  formed  a 
complete  envelope,  at  the  bottom  of  which  .there  was  the  bul- 
let as  in  the  preceding  case.  In  this  situation  and  in  order  to 
relieve  the  painful  twitchings  which  he  felt,  the  wounded 


Foreign  Bodies.  33 

soldier  was  obliged  to  keep  himself  in  a  bent  position.  Doc- 
tor Lacipière,  the  surgeon-major,  who  received  and  dressed 
the  wounded  man  at  the  ambulance  of  the  third  division  of 
the  first  army-corps,  after  having  enlarged  the  orifice  a  little, 
accomplished  the  extraction  of  the  double  foreign  substance 
without  any  difficulty.  There  was  no  other  unfavourable 
symptom,  nOr  did  the  testicle  sustain  any  alteration  whatever. 

Third  Observation.  Finally,  at  the  military  hospital  of 
Gros-Caillou,  in  the  early  part  of  January  1816,  we  have  had 
under  treatment  one  Alphonse  Marseille,  a  soldier  of  the  10th 
regiment  of  the  line,  now  belonging  to  the  corps  of  the  royal 
guards,  on  account  of  a  fistulous  sore,  of  two  or  three  lines  in 
diameter,  which  he  had  on  the  right  side  of  the  abdomen,  two 
fingers  breadth  or  thereabout  from  the  most  projecting  point 
of  the  edge  of  the  false  ribs.  The  causes  of  this  fistulous  sore, 
thus  penetrating  obliquely  from  the  right  to  left  and  inwards 
till  within  the  interior  of  the  abdominal  cavity,  were  by  that 
soldier  referred  to  the  following  circumstances: 

Whilst  in  Catalonia  with  the  10th  regiment,  in  April  1815, 
he  received,  during  a  fight  between  the  soldiers  of  the  same 
regiment,  a  shot  in  his  belly.  It  appears  that  the  bullet  hav- 
ing gone  in  the  direction  above  mentioned,  had  shoved  some 
part  of  his  shirt  before  it,  forced  itself  through  the  muscular 
substance,  and  at  last  penetrated  with  it  into  the  abdominal 
cavity.  The  wounded  man,  having  fallen  to  the  ground  after 
the  shot,  received  the  first  assistance  from  one  of  his  comrades, 
who  being  unable  to  pull  out  the  part  of  the  garment  which 
was  entangled  in  the  wound  of  the  abdomen,  cut  it  with  a 
knife  to  the  level  of  the  orifice. 

The  Spanish  surgeon  of  the  hospital  of  Figuières,to  which  the 
wounded  man  had  been  carried,  omitted  to  make  any  further 
search  after  it,  and  contented  himself  with  the  application  of  a 
simple  dressing  over  the  wound.  Soon  after,  however,  inflam- 
matory symptoms  made  their  appearance,  the  belly  became  tym- 
panitic, and  the  patient  passed  a  considerable  quantity  of  blood 
by  the  alvine  discharges;  this  sanguineous  evacuation  had  been 
preceded  by  a  violent  colic  and  repeated  disposition  to  vomit. 
Mild  beverages  and  emollient  cataplasms  having  been  resorted 
E 


34  Foreign  Bodies — Insects. 

to  for  several  days,  the  original  symptoms  subsided;  a  copious 
suppuration  became  established  in  the  wound,  and  after  about 
three  months,  the  same  surgeon,  guided  by  a  piece  of  linen 
which  had  shown  itself  at  the  bottom  of  the  wound,  enlarged 
the  border  of  the  latter  at  last,  seized  the  rag  with  his  fin- 
gers and  a  strong  pair  of  forceps,  extracted  it  altogether. 
This  piece  of  linen  formed  a  sac  of  about  four  inches  in  length, 
at  the  bottom  of  which  was  the  bullet.  From  that  moment 
the  patient  gradually  recovered,  and  was  soon  in  a  fit  condi- 
tion to  be  removed  from  one  hospital  to  another,  when  he 
subsequently  arrived  at  that  of  Gros-Calllou  at  Paris,  where,  as 
has  been  already  stated,  he  was  finally  admitted. 

There  is  one  more  remarkable  species  of  foreign  bodies 
which  we  cannot  pass  over  in  silence,  and  which  we  have  had 
an  opportunity  to  notice  with  the  majority  of  our  wounded  in 
Syria,  during  the  expedition  in  Egypt.  While  the  process 
of  suppuration  of  their  wounds  was  going  on,  the  wounded 
were  much  annoyed  by  the  worms  or  larvae  of  the  blue  fly, 
peculiar  to  that  climate.  These  insects,  hatched  in  a  few 
hours,  developed  themselves  with  such  rapidity  that,  from 
one  day  to  the  next,  they  grew  to  the  size  of  a  small  goose- 
quill,  which  greatly  terrified  our  soldiers,  whatever  we  might 
say  for  their  encouragement  to  the  contrary  notwithstand- 
ing. Nothing  short  of  experience  could  convince  them  that 
these  insects,  so  far  from  being  injurious  to  their  wounds, 
promoted  rather  their  cicatrization,  by  cutting  short  the 
process  of  nature,  and  by  Causing  the  separation  of  the  cellular 
eschars  which  they  devoured.  These  larvae  are,  indeed,  greedy 
only  after  putrefying  substances,  and  never  touch  the  parts 
v/hich  are  endowed  with  life;  under  these  circumstances  also 
we  have  never  seen  hemorrhage  occur,  whatever  might  have 
been  the  depth  to  which,  according  to  the  extent  of  the 
injury,  these  insects  had  found  their  way.  Lotions  of  a  strong 
decoction  of  garlic,  of  rue  or  common  sage,  prepared  at  every 
time  of  dressing,  were  sufficient  to  cause  their  destruction;  but 
soon  after  they  were  reproduced,  owing  to  the  insufficiency  of 
the  proper  means  to  guard  against  the  approach  of  the  flies  and 
to  prevent  the  incubation  of  their  eggs.     But  this  may  be 


Treatment  of  Gun-shot  Wounds.  35 

readily   accomplished   by  soaking   Ihe  first  compress  of  the 
dressing  in  a  solution  of  camphor  or  any  other  antiseptic  fluid. 

Of  the  Treatment  of  Gun-shot  Wounds. 

We  shall  now  proceed  to  the  examination  of  the  indications 
which  gun-shot  wounds  present  at  their  different  periods;  but 
before  we  make  known  these  indications,  we  will  point  out  a 
highly  important  rule  which  has  not  at  all  been  disposed  of 
by  writers.  It  relates  to  the  order  of  dressing  a  patient  who 
has  been  wounded  in  several  places.  This  rule  then  consists, 
after  commencing  with  the  dressing  of  the  most  simple  and 
least  important  injury,  to  proceed  with  that  of  a  more  serious 
one,  and  so  on  in  succession  to  thé  most  important,  more  par- 
ticularly if  this  should  command  a  painful  operation.  It  is  easy 
to  comprehend  at  once  the  reasons  of  this  method  of  proceed- 
ing. It  is  self  evident  that  if  a  beginning  were  made  with 
the  last  wound,  the  patient  might  be  seized  with  syncope  after 
the  operation,  which  would  render  it  necessary  to  postpone  the 
dressing  of  the  other  wounds;, or,  perhaps,  frightened  and  fa- 
tigued by  the  greater  or  lesser  intensity  of  the  pain,  subsequent 
to  the  operation  which  he  has  undergone,  he  might  decline 
any  further  assistance;  whilst,  on  the  other  hand,  the  cares  be- 
stowed upon  the  more  trifling  wounds  being  less  painful,  the 
wounded,  encouraged  by  it,  has  not  near  so  much  cause  to  dread 
the  treatment  of  the  more  serious  ones. 

During  their  first  period  gun-shot  wounds  require  a  simple, 
slightly  tonic  and  compressive  treatment;  tonic,  in  order  to  re- 
store the  weakened  action  of  the  blood-vessels  underneath  the 
eschar  of  attrition,  whereby  the  exfoliation  of  the  latter  is  pro- 
moted and  the  wound  is  promptly  cleansed;  compressive,  in  or- 
der to  prevent  too  considerable  a  swelling  of  the  injured  parts, 
and  to  excite  the  reaction  of  the  blood-vessels.  Now,  then,  with 
a  view  to  accomplish  this  twofold  indication,  a  linen  rag,  with 
holes  in  it  (fenêtre)  soaked  in  warm  camphorated  wine,  or  in  salt 
water  (eau  marinée),  with  a  few  drops  of  the  acetate  of  lead  in 
solution,  should  be  immediately  applied,  and  secured  by  com- 
presses and  rollers,  or  many-headed  bandages,  soaked  in  the 
same  fluid;  taking  care  that  the  pressure  of  the  bandage  to  be 


36  Treatment  of  Gun-shot  Wounds. 

employed  be  uniform.  We  contrived  this  method  of  dressing 
about  the  beginning  of  the  campaign  of  the  army  of  the  Rhine, 
inl792,  and  from  that  period  have  constantly  made  use  of  it. 

In  case  symptoms  of  local  erethlsmus  or  general  plethora 
should  come  on,  the  vascular  system  requires  then  to  be  re- 
duced by  blood-letting,  diluents,  and  thin  broths.  The  em- 
ployment of  leeches,  so  much  extolled  by  the  physicians  of 
the  present  day,  cannot  be  but  improper,  in  as  much  as  they 
augment  the  stagnation  of  the  fluids  in  the  blood-vessels  of  the 
disordered  parts,  which  intumesce  and  become  affected  with 
gangrene.  Besides,  the  application  of  leeches  requires  the 
dressing  of  the  wound  to  be  taken  off,  when  the  want  of  com- 
pression which  must  result  from  it,  would  be  sufficient  alone  to 
induce  the  swelling  and  all  the  other  symptoms  which  have 
just  been  enumerated. 

If  gun-shot  wounds  are  attended  with  hemorrhage,  they 
must  necessarily  be  enlarged,  so  as  to  lay  open  the  arteries,  and 
apply  to  them  the  mediate  or  immediate  ligature;*  the  latter, 
if  practicable,  should  always  be  preferred.  The  same  measure 
is  also  indicated  when  the  wounds  extend  over  the  fleshy  and 
aponeurotic  parts,  and  when  in  their  interior  there  are  obstruc- 
tions of  such  a  nature  as  to  occasion  strangulation,  or  extensive 
denudations,  which  may  have  destroyed  the  vascular  commu- 
nications and  the  relative  connexion  of  parts.  Gun-shot 
wounds,  on  the  contrary,  in  parts  of  the  body,  where  there  are 
neither  muscles  nor  aponeuroses,  such  as  the  periphery  of  the 
cranium,  the  sternal  region,  and  the  surface  of  certain  articula- 
tions, must  not  be  enlarged,  unless  for  the  purpose  of  searching 
after  some  artery  with  a  view  of  applying  a  ligature,  or  in  order 
to  divide  some  lacerated  nervous  cords;  finally,  these  enlarge- 
ments, should  they  become  necessary,   must  be  made  with 


*  The  French  surgeons  understand  by  the  mediate  ligature  that  which,  besides 
the  divided  artery,  includes  also  the  surrounding  cellular  tissue  and  muscular 
fibres,  as  in  cases  where  the  artery  has  much  retracted  within  the  muscular  sub- 
stance, and  is  not,  of  course,  within  reach  of  either  forceps  or  tenaculum.  The 
immediate  ligature  is  that  which,  after  the  artery  has  been  seized  and  drawn  out 
by  a  common  dissecting  forceps,  is  at  once  brought  to  bear  upon  the  blood-ves- 
sel to  be  secured  thereby. — Translator. 


Treatment  of  Oun-shot  Wounds.  37 

circumspection,  lest  any  blood-vessels,  nerves  or  tendons,  be- 
fore uninjured,  might  be  affected. 

This  indication  being  fulfilled,  the  edges  of  the  wound  are 
to  be  drawn  together  and  kept  in  their  place  by  means  of 
perforated  rags,  spread  with  some  balsamic  substance,  or  soak- 
ed in  warm  wine  or  salt-water,  &c.  ;  scraped  lint  or  hemp, 
secured  by  compresses,  are  next  to  be  applied  over  it  to  absorb 
the  fluids,  and  the  application  of  an  appropriate  bandage  will 
complete  the  dressing. 

This  dressing,  except  for  some  imperative  reason,  must  not 
be  touched  before  the  seventh,  eight  or  ninth  day;  for  it  is  of 
great  consequence  to  wait  till  suppuration  has  cleansed  the 
parts,  and  spontaneously  loosened  the  pieces  of  the  dressing; 
and  it  is  attended  with  considerable  mischief  to  prematurely  re- 
move them,  especially  in  the  winter  season.  We  have  seen  a 
great  many  individuals  who  had  undergone  the  operation  for 
amputation  of  the  shoulder  or  arm,  travelling  over  immense 
distances,  from  the  field  of  battle  to  their  ulterior  destination, 
wihout  their  being  dressed  again.  All  they  did  was  to  sponge 
the  exterior  of  the  dressing  daily,  and  cover  it  with  a  piece  of 
skin,  or  oil-cloth,  or  any  other  material,  when,  nevertheless, 
these  men  after  their  arrival  saw  their  stumps  cicatrized,  or 
far  advanced  in  the  cicatrization.  The  ligatures  and  sloughs 
having  come  off  of  their  own  accord,  were  found  within  the 
dressing.  Amongst  others,  a  chief  of  a  battalion,  whose  arm 
had  been  amputated  at  the  shoulder,  repaired  from  the  battle  of 
the  Moscowa  to  Paris,  without  being  dressed  once,  and  at  his 
arrival  in  the  latter  city  found  his  stump  completely  cicatrized. 
He  daily  wiped  off"  with  a  sponge  the  suppurated  matter  which 
ran  over  the  dressing  which  had  been  applied  by  me  after  the 
operation.  General  Janin,  one  of  the  warriors  of  the  old  army 
who  in  the  action  of  Elsberg  in  Prussia  had  the  jaw-bone  shatter- 
ed and  a  large  portion  of  the  lower  lip  and  of  the  cheek  destroy- 
ed by  a  biscayan,  secured  the  complete  success  of  the  operation 
which  I  performed  on  him  upon  the  field  of  battle,  by  carefully 
retaining  the  methodically  applied  dressing,  until  he  arrived 
at  Paris,  where  he  caused  the  ends  of  the  suture  over  the  al- 
ready united  cicatrix  to  be  cut  off". 


38  Treatment  of  Gun-shot  Wounds. 

If  these  wounds  are  complicated  with  fracture  or  shattering 
of  the  bones,  it  becomes  likewise  indispensable  to  cut  down  in 
order  to  ascertain  the  internal  injury;  extract  the  moveable, 
isolated  or  displaced  fragments;  reset  those  of  which  there  is 
some  hope  of  their  uniting  again  with  the  rest  of  the  bone; 
and  perform  in  some  instances  the  operation  of  resection.* 
As  to  the  dressing  of  these  kinds  of  wounds,  it  differs  in  no 
way  from  that  above  described.  We  shall  elsewhere  more 
fully  dwell  upon  such  fractures. 

This  then  is  a  summary  of  the  principles  which  are  to  be 
acted  upon  in  gun-shot  wounds  of  a  recent  date;  but  if  other 
symptoms  have  come  on,  blood-letting  will  be  required  ac- 
cording to  the  intensity  of  the  local  inflammation,  as  charac- 
terized by  the  tumefaction  and  the  more  or  less  vivid  redness 
of  the  parts,  the  heat  and  some  kind  of  deep  and  troublesome 
pulsation,  and  according  to  the  state  of  turgescence  under 
which  the  patient  labours.  General  blood-letting  is  preferable 
to  leeches  which,  so  far  from  dispersing  the  inflammation,  in- 
crease it  and  invite  an  attack  of  gangrene.  We  know  a  great 
many  instances  of  such  a  result,  of  which  we  shall  endeavour 
to  give  an  explanation  in  the  article  on  compound  fractures 
of  the  lower  extremities,  in  another  volume.  Equal  circum- 
spection is  required  in  the  use  of  emollient  applications  to  the 
engorged  parts.  Mild  tonics  and  an  uniform,  but  careful 
pressure,  are  almost  always  more  serviceable.  A  rigid  diet 
and  cooling  drinks  are  indicated. 

If,  notwithstanding  these  measures,  the  inflammation  should 
not  be  disposed  to  terminate  in  resolution,  and  be  converted 
into  an  erysipelatous  affection,  or  if  it  should  terminate  either 
by  an  excessive  suppuration,  or  by  hospital  gangrene,  or 
finally  b}^  gangrene,  the  disastrous  consequences  of  each  of 

•  The  operation  of  resection  refers  to  the  surgical  practice  of  cutting  off  the 
articulating  extremities  of  the  bones,  or  of  some  portion  of  their  continuity,  as 
in  cases  of  disunited  fractures,  where  the  extremity  of  th'e  bony  fragment  is  cut 
off.  This  operation  has  been  successfully  performed  on  the  head  of  the  hume- 
rus, on  the  elbow-joint',  the  radio-carpal  articulation,  the  ribs,  the  femur,  the 
knee-joint,  the  inferior  maxilla,  &c.  The  performance  of  it  requires  the  utmost 
circumspection  in  the  management  of  the  large  blood-vessels  and  nerves,  as  well 
as  the  tendons  which  are  attached  to  these  articulations. — Translator. 


TVaumatic  Erysipelas.  39 

these  affections  may  be  prevented  by  the  measures  which  we 
are  about  to  mention  successively. 

Of  Traumatic  Erysipelas. 

The  erysipelas  which  in  the  vicinity  of  a  wound  supervenes 
after  the  fourth  or  fifth  day  from  the  occurrence,  necessarily 
acknowledges  its  essential  cause  to  exist  in  an  over-excitement 
of  the  nervous  and  vascular  systems  of  the  deeper  situated 
edges  and  walls  of  such  a  wound,  an  excitement  which  is  or- 
dinarily produced  by  their  too  sudden  union,  more  particularly 
when  the  division  has  not  been  simple  and  uniform  like  that 
which  is  made  by  the  instrument  of  the  surgeon. 

The  use  of  agaric-tents  or  other  foreign  bodies  introduced 
into  this  solution  of  continuity;  the  application  of  greasy  or 
too  irritating  substances,  or  even  of  emollients  at  an  excessive 
temperature;  the  contact  with  the  cold  and  moist  air;  the  state 
of  attrition  and  laceration  of  the  injured  parts,  or  some  gas- 
tro-bilious  affection,  are  so  many  causes  which  may  give  rise 
to  this  over-excitement.  An  impression  once  made  upon 
these  injured  and  highly  irritable  parts,  produces,  on  one  hand, 
the  curling  and  the  erethismus  of  the  ruptured  vessels  of  the 
organs  which  ought  to  induce  the  suppuration  and  the  dis- 
gorgement of  the  inflamed  tissues;  on  the  other,  the  capil- 
lary veins  of  the  cutis  (which,  from  their  nature  and  super- 
ficial situation,  do  not  participate  to  the  same  degree  in  that 
deep  erethismus)  absorb  the  fluids  poured  out  into  the  wound, 
and  transmit  them  by  a  kind  of  peristaltic  and  divergent  con- 
traction towards  the  external  surface,  so  as  to  occasion  the  ery- 
sipelas just  spoken  of.  If  this  absorption  takes  place  imme- 
diately after  the  wound  has  been  inflicted,  either  because  of 
its  being  closed  up,  or  because  of  its  being  left  altogether  to  the 
resources  of  nature,  the  consequence  will  be  a  more  or  less 
extensive  ecchymosis,  produced  in  either  case  by  the  passage 
of  the  arterial  blood  into  the  cutaneous  veins,  which  absorbed  it 
in  the  interior  of  the  wound,  and  carried  it  to  distances  pro- 
portionate to  the  causes  of  local  irritation  and  disturbance. 
In  case  the  fluids,  poured  out  within  the  wound,  have  been 
changed,  so  as  to  present  a  purulent  character,  their  absorp- 


40  Traumatic  Erysipelas. 

tion  by  the  same  vessels  will  afterwards  cause  an  erysipela- 
tous affection  to  be  developed,  for,  at  the  same  time  that  these 
morbid  principles,  in  their  passage  through  these  vessels  pro- 
voke a  spasmodic  contraction  of  their  coats,  the  blood  contain- 
ed within  them  is  rendered  even  more  fluid,  owing  to  the  effects 
of  the  increased  heat  of  the  part,  as  well  as  to  its  mixture  with 
the  purulent  and  acrid  molecules  taken  up  in  the  wound.  All 
these  causes  produce  the  fulness  of  the  epidermis  and  the 
redness,  the  intensity  of  which  is  augmented  by  its  coming  in 
contact  with  the  oxygen  of  the  atmospheric  air.  In  conse- 
quence then  of  this  continued  reaction  of  irritation  and  infection, 
the  erysipelas  increases  and  spreads  rapidly  over  the  same  re- 
gions, and  stops  only  at  the  more  or  less  firm  adhesions  of  the 
integuments,  such  as  those  which  extend  over  the  bony  projec- 
tions. If  afterwards,  in  addition  to  its  traumatic  origin,  there 
should  be  combined  with  it  some  deleterious  miasma  arising 
from  mephitical  exhalations,  or  from  some  focus  of  contagious 
disease,  the  erysipelas  will  then  promptly  terminate  in  gan- 
grene; and  as  this  latter  affection  paralyses  in  its  turn  the  vital 
principle  of  the  internal  organs,  the  cessation  of  the  vital 
functions  in  the  injured  tissue,  and  soon  afier  the  total  de- 
struction of  the  individual  will  be  the  result,  unless  the  pro- 
gress of  the  mortification  can  be  arrested  or  circumscribed. 

In  the  case,  however,  of  the  presence  of  some  bilious  de- 
rangement, the  erysipelas  and  the  wound  assume  a  yellowish 
tint  and  become  complicated  with  symptoms  of  hepatitis. 
Finally,  if  there  exist  any  signs  of  an  atonic  condition  of  the 
stomach,  accompanied  by  sour  eructations  or  nausea,  the  ery- 
sipelatous exanthema  grows  pale,  the  edges  of  the  solution  of 
continuity  become  bloated,  and  its  bottom  is  covered  with  a 
thick  grayish  and  putrescent  substance,  which  characterizes  the 
adynamia  and  hospital  gangrene. 

We  have  already  pointed  out  the  measures  to  be  adopted 
for  the  purpose  of  preventing  or  dispersing  the  ecchymosis 
which  is  an  attendant  upon  wounds  and  contusions;  we  now 
propose  to  treat  exclusively  of  the  traumatic  erysipelas  which 
is  a  modification  only  of  ecchymosis,  for  the  difference  of 
both  these  two  species  of  pathological  injection  holds  only 


Traumatic  Erysij^elas.  41 

with  respect  to  the  nature  of  the  fluids  which  circulate  through 
the  infiltrated  vessels.  Now,  erysipelas  is  produced  by  the 
admixture  of  a  greater  or  lesser  quantity  of  purulent  molecules 
with  the  venous  blood,  whilst  the  blood  effused  into  the  wound 
by  the  divided  or  lacerated  arterioles,  taken  up  again  by  the 
veins  and  extravasated  on  the  surface  of  the  skin,  or  within 
the  subcutaneous  cellular  tissue,  is  what  constitutes  an  ecchy- 
mosis;  yet  the  tissues  are  not  by  any  means  inflamed,  and 
therefore  the  indication  cannot  be  one  and  the  same. 

What,  then,  is  most  proper  to  be  done  in  erysipelas }  The 
plans  of  treatment  devised  are  as  numerous  as  the  authors 
who  have  written  on  this  affection;  but  most  all  of  them, 
and  especially  those  who  have  embraced  the  doctrines  of 
Broussais,  advise  capillary  depletions  by  means  of  leeches  ap- 
plied to  the  erysipelas,  as  the  first  and  most  important  remedy 
to  be  employed.  These  writers  believe  that  by  thus  empty- 
ing the  engorged  vessels  the  disorder  can  be  entirely  arrested, 
because  in  the  first  place  the  intensity  of  the  colour  is  di- 
minished, and  on  the  other  hand  the  pains  are  relieved  and 
frequently  subdued  altogether.  This  is  apt  to  mislead,  how- 
ever, for  the  local  depletion  by  leeches  does  not  operate 
upon  the  injected  or  erysipelatous  vessels.  These  animals 
rather  avoid  them,  and  directing  their  pointed  and  cutting 
fangs  deeper,  go  in  search  after  the  arterioles  at  the  bot- 
tom of  the  dermoid  tissue,  which  they  open  in  preference,  in 
order  to  suck  the  vital  blood,  instead  of  imbibing  the  puriform 
sanguineous  fluid  which  is  contained  in  the  superficial  veins.* 
The  pathological  engorgement  remains  stationary  there- 
fore; the  vehicle  only  of  life  is  reduced;  the  sensibility  is 
blunted;  the  functions  of  the  individual  are  impaired,  and  the 
vital  properties  are  extinguished  within  the  engorged  parts, 

♦  I  have  investigated  the  distribution  of  the  vessels  of  which  the  dermoid  tissue 
is  composed,  in  the  anatomical  preparations  and  very  fine  injections  which  I  have 
seen  in  Germany,  in  the  cabinets  of  the  celebrated  Prochaska  and  Soemmering. 
These  injections,  of  some  of  which  I  am  possessed,  are  quite  well  enough  pre- 
pared to  plainly  distinguish  with  the  microscope  the  two  layers  of  vessels.  The 
most  superficial  is  entirely  composed  of  veins,  and  the  next  of  arterial  vessels 
which  extend  far  through  the  more  or  less  compact  net  work  in  the  interior  ol 
the  dermoid  texture. 

F 


42  Traumatic  Erysipelas. 

which  become  forthwith  struck  with  numbness,  and  soon 
after  with  a  gangrenous  disorder,  the  progress  of  which  it  is 
difficult  subsequently  to  arrest.  Moreover,  the  instantaneous 
irritation  which  the  leeches  excite  in  the  dermoid  system,  is 
sufficient  to  determine  the  disorder  to  assume  a  phlegmonous 
character,  by  propagating  the  erysipelas  as  far  as  the  cellular 
texture;  a  result  the  more  disastrous,  as  this  tissue  is  scarcely 
inflamed,  when  a  degree  of  suppuration  becomes  established, 
the  effects  of  which  extend  still  farther  by  the  production 
of  sinuses  and  purulent  discharges,  which  result  in  the  denu- 
dation of  the  skin  and  muscles,  and  in  the  more  or  less  exten- 
sive destruction  of  that  very  same  cellular  texture.  Emollient 
applications,  whatever  may  be  their  mode  of  preparation,  in- 
crease likewise  the  general  relaxation,  the  engorgement,  and 
give  rise  to  analogous  symptoms.  The  topical  repellents  and 
rubefacients  which  are  recommended  by  some  writers,  are  at- 
tended by  the  still  greater  inconvenience  of  heightening  and 
spreading  the  inflammation  farther,  whilst  the  excoriations 
produced  by  the  latter  topical  means  are  often  followed  by 
gangrene. 

This  variety  of  remedies,  and  the  usually  distressing  con- 
sequences which  resulted  from  them,  have  led  several  physi- 
cians to  say  that  the  cure  of  this  disease  ought  to  be  left 
to  nature;  but  she  is  rarely  sufficient  for  herself;  and  if  art 
could  not  promptly  afibrd  her  relief,  she  might  perhaps  be 
overcome;  for  there  frequently  occurs  some  kind  of  metastasis 
by  which  the  morbific  principles  which  produce  this  exanthe- 
ma, are  transferred  to  the  internal  organs,  so  that  if  the  patients 
be  not  destroyed  in  consequence  of  the  deleterious  and  conta- 
gious effects  of  the  local  gangrene,  they  perish  from  the  sym- 
pathetic and  consecutive  affections  of  the  viscera.  We  have 
witnessed  a  great  number  of  instances  which  have  prevailed 
with  us  to  make  new  investigations,  and  to  study  with  scrupu- 
lous attention  the  development  of  this  traumatic  erysipelas, 
whose  march  is  so  rapid,  and  the  career  of  which  it  is  so  import- 
ant to  arrest  in  order  to  prevent  its  almost  uniformly  fatal 
results. 

Without  regard  to  the  causes  concomitant  upon  the  forma- 
tion of  this  disorder,  some  remedy  must  be  promptly  employed. 


Traumatic  Erysipelas.  43 

capable  of  arresting  this  peristaltic  inflammatory  action,  by 
absorbing  the  morbid    principle  along  with   the  fluids  which 
harbour  it,  and  by  restoring  at  the  same  time  the  vital  proper- 
ties to  the  diseased  tissues,  from  which  this  morbific  stagna- 
tion had  expelled  them.     The  actual  cautery  has  appeared  to 
us  to  produce  this  double  effect,  and   the  most  extraordinary 
success  has  warranted  our  attempt.     Towards  the  end  of  the 
last  century,  M.  Pelletan  (of  the  Institute  of  France),  whose 
eloquent  lectures  furnished  the  majority  of  the  luminous  ideas 
which  have  led  the  modern  physiologists  to  so  many  disco- 
veries, had  already  pointed  out  this  local  application  as  a  pow- 
erful revulsive  in  erysipelas.     Applied  to  the  reddest  spots  of 
the  erysipelas,  and  to  those  which  are  nearest  to  the  wound,  the 
incandescent  iron  arrests,  indeed,  instantaneously,  the  progress 
of  the  phlegmasia.    This  application,  which  gives  butlittle  pain, 
if  any  at  all,  is  attended  and  followed  immediately — 1st,  by 
a  gaseous  effluvia  of  an  animal  odour,  rendered  visible  by  some 
slight  smoke,  in  which  it  is  enveloped;  2dly,  by  the  disappear- 
ance of  the  heat  and  painful  tension  which  the  patient  be- 
fore experienced  all  over  the  inflamed  part;  3dly,  by  a  disper- 
sion of  the  redness  and  swelling  before  perceptible;  4thly,  these 
cauterizations  are  no  ways  followed   by  suppuration,  or,  like 
the  rubefacients,  are  capable  of  producing  gangrene:  the  burn- 
ed portions  of  the  cutis  fall  off  in  small  carbonaceous  scales, 
and  leave  no  sensible  cicatrix;  5thly,  the  purulent  flow  of  the 
wound,  the  suppression  of  which  preceded  the  erysipelas,  be- 
comes almost  immediately  re-established;  6thly  and  finally,  the 
powers  of  the  patient  revive  at  the  same  time,  and  the  impaired 
functions  of  the  viscera,  particularly  those  of  the  stomach,  rally 
asain  and  thus  contribute  to  the  entire  resolution  of  the  exan- 
thematous  disorder.     Besides,  if  there  should  yet  remain  some 
symptoms  of  a  gastro-intestinal  affection,  the  revulsive  effects 
of  the  actual  cautery  will  be  completed  by  the  exhibition  of 
one  grain  of  emetic  tartar,  dissolved  in  a  cold  and  strained  in- 
fusion of  ipecacuanha. 

Such  are  the  facts.  But,  how  shall  we  explain  the  pheno- 
mena which  we  have  just  dwelled  upon?  The  solution  of 
this  question  I  leave  to  physiologists;  I  have  intended  nothing 


44  Traumatic  Erysipelas. 

further  than  to  draw  the  attention  of  practitioners  to  the  effi- 
cacy of  the  actual  cautery  in  comhating  the  disease  in  question. 
Nevertheless,  we  shall  endeavour  to  account  to  ourselves  for 
the  cause  of  several  of  these  phenomena,  the  existence  of  which 
seems  scarcely  credible,  if  the  sources  of  their  production  could 
not  be  so  clearly  demonstrated. 

1 .  We  have  stated  that  the  application  of  the  red-hot  iron 
to  the  erysipelatous  inflorescence  is  made  without  giving  any 
very  sensible  pain.  We  believe  that  this  insensibility  must  be 
ascribed  to  the  more  or  less  condensed  layer  of  vascular  net- 
work which  has  been  injected  and  covered  up  by  the  already 
disorganized  epidermis,  so  that  this  layer  isolates  and  protects 
the  nervous  tissues  of  the  skin. 

2.  The  burns  do  not  suppurate,  because  the  cautery  has 
spared  also  the  sensible  texture  of  the  dermoid  tissue,  in 
which  the  arterial  vessels  reside,  which  alone  are  capable  of 
bringing  on  suppuration.  Indeed,  if  thered-hot  iron  is  quickly 
and  gently  applied  to  the  erysipelatous  exanthema,  as  in  such 
a  case  ought  to  be  done,  the  cauterization  will  be  confined 
to  the  vessels  which  are  injected  and  in  some  measure  deprived 
of  vitality;  and  in  that  manner  the  little  eschars,  thereby  pro- 
duced, come  off  in  dry  and  carbonaceous  scales,  and  the  epi- 
dermis all  over  that  part  of  the  skin  which  has  been  attacked 
by  the  erysipelas,  falls  off  in  more  or  less  compact  scales. 

3.  Finally,  as  the  dermoid  tissue  had  not  been  encroached 
upon,  as  we  have  just  now  stated,  the  burnt  places  cannot,  of 
course,  leave  any  cicatrix. 

But,  in  order  to  prove  the  efficacy  of  the  actual  cautery,  we 
shall  detail,  as  briefly  as  possible,  the  observations  made  on  seve- 
ral individuals,  in  whom  the  gentle  and  prompt  application'of 
this  revulsive  caused,  as  if  by  enchantment,  the  disappearance 
of  the  traumatic  erysipelas;  together  with  the  adynamic  and 
anomalous  fever  which  accompanied  it.  We  have  not  kept  an 
account  of  the  several  experiments  which  we  have  instituted 
at  different  periods,  because  we  could  not  completely  follow  up 
their  ^ffectsj  we  shall  therefore  confine  ourselves  to  a  state- 
ment of  the  following  observations. 

First  Observation.     John  Féton,  aged  22,  a  gunner  in  the 


Traumatic  Erysipelas.  45 

horse-artillery  of  the  guards,  was  brought  to  the  hospital  on 
the  5th  October  1825,  that  being  the  sixth  clay  after  he  had  re- 
ceived a  contused  wound  on  the  right  leg  from  the  kick  of  a 
horse,  the  impression  being  made  with  so  much  force  that  a  por- 
tion of  the  tibia  was  denuded.  During  the  first  few  days  gentle 
repellents  had  been  applied  to  this  solution  of  continuity;  but 
symptoms  of  local  inflammation  coming  on  towards  the  fifth 
day,  emollients  were  substituted.  After  that,  the  wound  as- 
sumed an  erysipelatous  character,  signs  of  a  general  nervous 
affection  began  to  show  themselves,  and  soon  after  the  erysi- 
pelas increased  and  rapidly  spread  over  the  whole  leg  and  foot, 
both  of  which  became  tumefied.  On  the  eleventh  day,  well 
marked  reddish  lines  extended  far  up  the  thigh,  and  small 
gangrenous  vesicles  began  to  appear  round  the  wound.  At  the 
time  when  this  gunner  was  brought  into  the  surgical  ward, 
the  animal  sensibility  of  the  whole  limb  was  already  extinct,  or 
at  least  considerably  blunted,  whilst  the  limb  itself  was  much 
bloated  and  of  a  reddish  purple  colour.  The  patient  was  trou- 
bled with  nausea,  vertigo,  and  complained  of  numbness  and  an 
unpleasant  heaviness  in  the  leg;  his  pulse  was  small  and  fever- 
ish; the  tongue  black  and  dry;  the  eyes  dull  and  watery;  the 
countenance  wan;  urine  scanty  and  dark;  and,  in  short,  the 
whole  announced  imminent  danger. 

We  immediately  administered  to  him  an  emetic,  after  the 
formula  above  mentioned,  succeeded  by  the  chicken  broth 
emulsion  and  by  mucilaginous  drinks,  sweetened  and  aroma- 
tized with  orange  flower  water.  The  diseased  limb  was 
enveloped  in  compresses,  soaked  in  hot  and  strongly  cam- 
phorated vinegar.  Finding  at  our  next  visit,  on  the  following 
day,  the  erysipelas  still  in  the  same  condition,  and  the  ataxia, 
which  existed  nearly  to  the  same  degree,  threatening  the  pa- 
tient all  the  time  with  impending  dissolution,  we  decided  on 
the  application  of  the  actual  cautery  to  all  the  principal  places 
of  erysipelatous  engorgement,  by  commencing  with  the  red 
streaks  on  the  thigh,  and  afterwards  by  descending  successively 
to  the  knee,  leg  and  foot,  taking  care,  however,  to  leave  con_ 
siderable  distances  between  the  cauterized  spots,  and  to  avoid 
the  cutaneous  adhesions  to  the  bony  projections.      Fifty  irons 


46  Traumatic  Erysipelas. 

heated  to  incandescence  were  thus  put  on  in  less  than  six 
minutes,  besides  whicli  we  applied  one  more  to  the  epigastrium. 
Compresses  soaked  in  the  before  mentioned  tonic  lotion  were 
placed  over  the  limb,  and  secured  by  means  of  a  moderately 
tight  bandage;  internally  the  same  remedies  were  prescribed. 
Our  surprise  was  extreme,  when  on  our  next  visit  we  found 
the  erysipelas  almost  entirely  gone,  and  the  swelling  of  the 
limb  considerably  reduced.  A  good  suppuration  was  already 
re-established  in  the  wound;  the  tongue  was  moist  and  less 
black;  all  the  functions  were  revived,  and  the  patient  who, 
the  day  before,  could  not  utter  one  word,  declared  with  a  loud 
voice  that  he  was  better.  He  had  on  the  same  day  several  dark 
and  extremely  fetid  alvine  evacuations.  The  dressing  of  the 
limb  was  renewed,  and  the  same  regimen  and  remedial  treat- 
ment continued.  In  less  than  three  days  all  the  symptoms  of 
the  erysipelatous  affection  and  traumatic  fever  had  entirely 
disappeared;  the  wound  began  to  assume  a  healthy  appearance, 
and  the  tumefaction  of  its  edges  subsided;  a  piece  of  bone  sub- 
sequently ex-foliated,  immediately  after  which  the  cicatrix  was 
formed.  Convalescence  was  now  no  longer  doubtful,  and  we 
were  enabled  to  announce  the  recovery  of  the  patient  and  his 
removal  from  the  hospital,  which  took  place  on  the  1st  of  De- 
cember following.  The  burns  from  the  heated  iron  had  never 
been  attended  by  suppuration,  and  have  left  no  mark  whatever 
on  the  skin,  where  the  cautery  had  been  applied. 

Second  Observation.     The  subject  of  the  second  observa- 
tion is  one  V (Nicolas),  a  private  of  the  5th  regiment  of 

infantry  of  the  guards.  At  the  time  of  admission  into  the  hos- 
pital, on  November  25,  1825,  this  man  had  received,  five 
days  before,  a  small  wound  upon  the  head,  which  was  situated 
on  the  lateral  and  superior  region  of  the  forehead,  and  had 
been  occasioned  by  some  contunding  body,  the  shock  of  which 
was  connected  with  a  very  trifling  rent  of  the  pericranium, 
and  a  pretty  extensive  denudation  of  the  frontal  bone.  A 
simple  dressing  had  been  applied  and  continued  to  the  period  of 
his  entering  the  hospital.  After  that,  an  erysipelatous  en- 
gorgement, sufficiently  distinct,  presented  itself  in  the  face, 
as  well  as  over  the  whole  surface  of  the  head;  still  there  were 


Traumatic  Erysipelas.  47 

no  febrile  symptoms  as  yet,  and  scarcely  did  the  patient  ex- 
perience some  transient  pain  in  the  head,  with  an  unpleasant 
heaviness  of  that  part.  The  extensive  denudation  of  the  bone, 
which  we  discovered  with  the  aid  of  a  probe,  and  the  quantity 
of  sanguineous  fluid  which  we  found  effused  between  the 
integuments  and  the  cranium,  induced  us  to  make  a  cru- 
cial incision  through  this  portion  of  the  skin,  the  centre  of 
which  being  formed  by  the  pre-existing  solution  of  continuity; 
this  division  was  accompanied  with  some  trifling  efiusion  of 
blood,  after  which  it  was  dressed  with  a  perforated  linen  rag, 
spread  with  saffron  cerate,  and  a  simple  retaining  apparatus  ap- 
plied over  it. 

The  patient  felt  somewhat  relieved  by  this  operation;  how- 
ever, on  m}'  visiting  him  the  next  day,  the  erysipelas  of  the 
face  had  become  fully  developed,  and  prevented  him  from 
opening  his  eye-lids;  it  extended  to  the  ears,  over  the  shoulders 
and  the  whole  neck.  Some  febrile  action  had  manifested  it- 
self likewise,  and  the  tongue  was  dry  and  covered  with  a  brown 
crust;  in  other  respects  the  lips  of  the  wound  were  disposed  to 
suppurate,  and  presented  nothing  remarkable.  We  prescribed 
mild  mucilaginous  drinks  and  purgative  enemata;  but,  on  the 
evening  of  the  same  day,  as  the  erysipelas  had  spread  still 
further,  and  the  fever  had  now  assumed  a  nervous  character, 
we  were  anxious  to  make  use  of  a  sufiiciently  large  number  of 
heated  irons,  which  we  applied  accordingly  to  the  temples, 
over  the  whole  posterior  region  of  the  head,  to  the  back  of  the 
neck  and  shoulders,  taking  care  only  to  apply  the  incandescent 
iron  at  proper  distances  and  with  the  utmost  despatch.  Com- 
presses, soaked  in  camphorated  vinegar,  were  put  over  the 
cauterized  spots,  and  in  other  respects  the  same  regimen  was 
continued. 

On  the  following  day  we  found  our  patient  sensibly  im- 
proved; the  erysipelas  had  almost  entirely  disappeared,  and 
resolution  continued  to  go  on  progressively.  The  suppu- 
ration of  the  wound  increased  in  the  same  proportion,  and 
on  the  tenth  day  the  disgorgement  of  the  whole  head  was 
completed.  At  length  the  functions  were  promptly  restored, 
and  before  the  nineteenth  day,  the   patient  was  in  a  fit  condi- 


48  vîbscesses,  <§'C. — Hospital  Gangrene. 

tion  to  get  out  of  bed  and  to  eat  some  light  food.  Towards 
the  thirtieth  day,  an  exfoliation  of  no  great  extent  had  taken 
place,  where  the  bone  had  been  denuded,  and  on  the  29th 
December,  forty  days  after  the  accident,  our  patient  left  the 
hospital,  with  his  wound  cicatrized,  and  his  health  perfectly 
restored. 

None  of  the  burns,  the  number  of  which  amounted  to  forty, 
were  followed  by  suppuration,  nor  have  they  left  any  sensible 
mark  upon  the  skin;  but  the  epidermis  of  the  integuments,  as 
far  as  the  erysipelatous  affection  had  been  established,  fell  off 
in  scales,  which  were  only  a  little  thicker  in  the  burnt  parts. 

Corresponding  results  from  the  application  of  the  incandes- 
cent iron  have  not  only  been  obtained  for  other  wounded,  who 
had  been  taken  with  traumatic  erysipelas,  but  likewise  in 
cases  of  simple  erysipelas,  whether  spontaneous  or  sympto- 
matic. 

Of  ^abscesses  or  Purulent  Sinuses,  subsequent  to  Wounds. 

If,  subsequent  to  the  solutions  of  continuity  which  engage 
our  present  attention,  abscesses  or  purulent  sinuses  should  be 
formed,  they  ought  to  be  opened  with  a  bistoury  and  their 
focus  laid  bare.  The  method  of  making  incisions  or  counter- 
openings  is  preferable  to  that  of  compression  which  has  been 
extolled  by  several  writers  and  by  many  practitioners.  The 
compression  has  the  great  inconvenience  of  causing  an  infil- 
tration and  extensive  diffusion  of  the  fluids  of  such  abscesses 
into  the  cellular  texture,  without  relief  to  the  original  injury, 
and  of  prolonging  or  aggravating  the  complaint. 

Of  Hospital  Gangrene. 

After  the  first  campaigns  in  Germany,  I  have  already  had  oc- 
casion to  remark  in  my  clinical  lectures  at  the  military  hos- 
pital of  the  guards,  that  the  hospital  gangrene  must  not  be 
confounded  with  gangrene,  and  that  both  these  diseases  pre- 
sented very  distinct  symptoms  and  a  career  totally  differ- 
ent. A  summary  of  the  observations  which  I  have  made 
upon  the  individuals  attacked  with  these  two  species  of  dis- 
eases, is  contained  in  the   case-books  of  surgical  observations 


Hospital  Gangrene.  49 

of  that  hospital,  and  in  my  memoirs  on  gangrene,  which  will 
be  the  next  subject  for  consideration. 

The  proximate  cause  of  the  former  of  the  two  affections  is 
to  be  found  in  an  increase  of  the  sensibility  of  the  injured  parts, 
which  is  induced  by  a  more  or  less  excitable  idiosyncrasy  of 
the  individual  and  by  his  predisposition  to  an  ad3niamic  state; 
by  the  moisture  of  the  atmosphere  and  by  too  long  an  expo- 
sure of  the  wound  to  the  miasmata  with  which  it  is  impreg- 
nated, particularly  those  which  are  the  product  of  a  similar 
disease,  or  of  putrid  emanations  from  animal  substances;  by 
the  use  of  too  irritating  ointments,  cold  and  astringent  lo- 
tions; improper  and  too  frequent  dressings.  When  it  is  in- 
duced by  a  spontaneous  adynamia,  its  invasion  is  ushered  in  by 
a  state  of  prostration  of  the  patient;  by  paleness  of  the  coun- 
tenance, whiteness  of  the  tongue,  which  is  covered  at  the 
base  with  a  crust  of  more  or  less  inspissated  yellowish  mu- 
cus, and  which  is  alike  observable  round  the  roots  of  the 
teeth;  by  quickness  and  smallness  of  the  pulse;  by  irregular 
shiverings,  anorexia  and  anxiety.  Dull  and  tensive  pains  be- 
gin to  be  felt  in  the  wound,  the  edges  of  which  swell,  and 
assume  a  purple  or  livid  aspect;  the  suppuration  diminishes 
sensibly  and  acquires  a  glutinous  character;  the  pains  increase, 
as  well  as  the  local  tumefaction.  This  soon  spreads  over  all 
the  points  of  the  solution  of  continuity,  the  spaces  of  which 
are  filled  up  with  a  pulpous  substance  of  a  grayish  colour, 
from  which  a  nauseating  odour  issues,  resembling  that  arising 
from  the  putrid  vegetable  glue  of  painters,  and  which  cannot 
be  compared  to  any  thing  better  than  to  the  grayish  film  Avhich 
may  be  observed  on  the  stagnant  waters  of  morasses.  This 
putrefaction  extends  itself  to  the  surface  of  the  wound,  the  tis- 
sues of  which,  especially  the  fibrous,  cellular  and  dermoid, 
it  is  prone  to  disorganize;  the  skin  curls  up  in  festoons,  as  it 
were,  and  readily  allows  itself  to  be  encroached  upon  by  this 
contagious  distemper,  which  quickly  spreads  from  one  point 
to  another  by  a  sort  of  successive  erosion,  with  which  it  acts 
upon  the  parts  accessible  to  its  influence;  it  penetrates  deeply 
into  the  interstices  of  the  muscles,  but  leaves  their  moveable 
fibres  untouched,  and  in  like  manner  allows  the  arteries  and 
G 


50  Hospital  Gangrene. 

nerves  to  escape,  because  these  organs  resist  the  effects  of 
these  putrid  morbific  substances,  in  consequence,  no  doubt,  of 
the  highly  active  vital  principles  essentially  contained  in  them, 
the  oxygen  which  circulates  with  the  blood  of  these  vessels,  and 
the  animal  electricity  which  pervades  the  nervous  cords;  thus, 
when  the  wounds  are  cleansed  and  freed  from  the  putrefactive 
matter,  the  muscles,  arteries  and  nerves  will  be  found  un- 
touched, and  are  pretty  speedily  filled  up  with  vascular  granu- 
lations. 

The  inoculation  or  transposition  of  the  putrefactive  matter 
to  other  simple  wounds,  though  their  cicatrization  shall  have 
advanced  already,  produces  there  the  same  kind  of  affection,  and 
soon  converts  them  into  putrid  ulcers,  similar  to  the  first.  In- 
struments and  dressing  rags  are  yery  often  excellent  conductors. 
This  inoculation  I  have  seen  performed,  and  have  observed  its 
progress  up  to  the  period  of  its  termination.  I  believe, 
therefore,  whatever  may  be  the  assertion  of  some  authors  to 
the  contrary,  that  the  contagious  tendency  of  this  disease, 
which  differs  essentially  from  gangrene,  can  be  no  longer 
doubtful.  The  effects  of  hospital  gangrene  are  to  attack  the 
integrity  of  the  internal  vital  organs  and  to  derange  or  weaken 
their  functions,  just  as  a  general  adynamic  state,  as  has  been 
before  mentioned,  will  induce  the  disorder  itself.  Thus,  in 
cases  of  the  most  simple  solutions  of  continuity,  the  exhibition 
of  an  emetic  in  season^  succeeded  by  the  use  of  good  bark, 
may  cause  the  nervous  or  general  putrid  affection  to  disappear, 
while  the  employment  of  certain  applications  to  the  wound, 
such  as  the  actual  cautery,  will  completely  destroy  this  gan- 
grene or  local  affection. 

After  the  development  of  these  symptoms,  it  will  be  easily 
understood  that  the  disease  which  now  occupies  our  attention, 
presents  three  stages,  which  it  is  useless  to  go  over  at 
present;  but  when  arrived  at  its  third  period,  it  then  travels 
with  frightful  rapidity,  and  in  such  a  manner  as  quickly  to  dis- 
organise the  dermoid,  cellular,  aponeurotic,  cartilaginous,  and 
even  osseous  tissues.  If  the  disease  has  spread  to  a  great 
extent,  the  ichorous  principle  of  the  secreted  matter  is  absorbed 
by  the  venous  system  and  transmitted  to  the  internal  organs. 
On  the  opening  after  death  of  persons  who  have  fallen  victims 


Hospital  Gangrene.  51 

to  this  complaint,  the  blood  of  the  veins  of  the  diseased  limb 
is  found  to  be  mixed  up  with  puriform  molecules  and  bubbles 
of  air  ;  there  are  purulent  sinuses  in  the  cellular  texture  and  in 
the  interstices  of  the  muscles,  and  finally  a  collection  of  matter 
or  putrid  serum  in  the  viscera,  particularly  those  of  the  diseased 
side  as  far  as  the  cerebral  membranes,  which  verifies  our 
opinion  on  the  true  causes  of  abscesses  of  the  liver,  subsequent 
to  injuries  of  the  head  ;  for  it  is  the  serous  tissue  of  these  organs 
which  is  always  the  most  affected,  whilst  the  mucous  mem- 
branes of  the  stomach  and  intestines  remain  unaltered.  Now, 
the  consequences  of  this  metastasis  and  of  these  sympathetic 
irritations  characterize  what  is  understood  by  adynamia. 

When  hospital  gangrene  appears  to  be  the  consequence  of  a 
gastric  nervous  affection,  the  topical  means  indicated  should  be 
preceded  by  an  emetic,  by  the  administration  of  bark,  or  rather 
the  sulphate  of  quinine  combined  with  camphor  and  opium, 
and  by  mild  mineral  or  acidulated  lemonades.  The  hydro- 
chloric acid,  which  ought  to  form  the  base  of  such  lemonades, 
has  appeared  to  us  to  produce  very  good  effects.  These  reme- 
dies frequently  arrest  the  progress  of  the  disease,  relieve  the 
stupor,  the  local  irritation,  and  promote  the  cleansing  of  the 
wound,  which,  of  its  own  accord,  casts  off  the  putrid  grayish 
film  which  covered  it,  and  very  soon  reassumes  a  vermilion 
appearance.  This  I  have  witnessed  many  a  time,  and  proves 
(though  contrary  to  the  opinion  of  the  Professor  of  Mont- 
pellier,* who  is  the  author  of  an  excellent  treatise  on  hospital 
gangrene)  that  it  may  be  symptomatic.  Most  commonly, 
however,  it  is  idiopathic. 

In  the  former  case,  as  in  the  latter,  after  having  fulfilled  the 
indication  relative  to  the  general  adynamia,  if  it  should  exist,  it 
is  necessary  to  persevere  with  the  remedies  which  are  most 
suitable  to  procure  both  the  removal  of  the  putrescent  matter 
and  the  final  draining  of  its  source.     The  Eau  de  Labarraque,t 

*  Mémoire  sur  la  complication  des  plaies  et  des  ulcères  connue  sous  le  nom 
de  Pourriture  d'Hôpital,  par  J.  Delpech.    Paris,  1815,  8vo. —  Translator. 

t  Eau  de  Labarraque,  or  disinfecting  soda  liquid,  prepared  first  by  M.  Labar- 
raque,  a  distinguished  chemist  and  pharmaceutist  of  Paris  ;  it  is  a  compound  of 
chlorine  and  soda,  analogous  to  the  well  known  bleaching  powder,  chloride  of 
lime.  It  may  be  obtained  easily  and  cheaply  by  decomposing  the  chloride  of 
lime  by  the  subcarbonate  of  soda.     Mix  one  part  of  dry  chloride  of  lime  with 


52  Gangrene. 

which  we  have  had  occasion  to  use  ever  since  its  discovery, 
(and  it  is  one  of  the  most  important  which  chemistry  has  made,) 
possesses  the  property  of  dissolving  that  substance  and  of  caus- 
ing its  disappearance  from  the  surface  of  the  wound.  Yet,  this 
remedy  will  by  no  means  destroy  the  cause  which  produced  it, 
and  so  far  from  obviating  the  deep  seated  irritation  which 
exists  in  the  solution  of  continuity,  it  appears  rather  to  main- 
tain it  by  its  slightly  caustic  or  corrosive  action.  But,  after 
using  this  or  whatever  other  remedy  may  be  calculated  to  re- 
move the  more  or  less  dense  layers  of  putrefaction,  the  actual 
cautery  may  be  used  with  the  greatest  advantage.  It  ought  to 
be  applied  while  the  iron  is  in  a  state  of  incandescence,  and 
care  should  be  taken  to  carry  it  sufficiently  deep  to  reach 
all  the  points  of  ulceration.  Occasionally  it  is  even  neces- 
sary to  repeat  the  cautery,  which,  so  far  from  being  an  act 
of  cruelty,  as  it  is  believed,  removes  the  pains  of  the  pa- 
tient, and  restores  him  to  a  state  of  ineffable  ease.  The 
latent  inflammation  is  promptly  dispersed,  the  wound  is  cleans- 
ed and  grows  bright  red,  and  the  cicatrization  afterwards  goes 
on  with  great  rapidity. 

Such  is,  in  a  summary  way,  the  origin  and  progress  of  this 
consecutive  complaint.  After  this  we  now  propose  to  examine 
the  complaint  which  we  have  designated  with  the  name  of 
traumatic  gangrene. 

Of  Gangrene. 
Gangrene  is  characterized  by  the  gradual  diminution  and 
entire  disappearance  of  sensation  in  the  injured  parts.  The 
suppuration  of  the  wounds,  where  it  exists,  is  less  abundant, 
and  becomes  fluid,  sanious,  and  of  a  blackish  colour  ;  it  very 
soon  forms  a  brown  or  black  slough,  more  or  less  thick,  soft  or 
compact,  according  to  the  nature  of  the  gangrene  ;  the  odour 
which  it  exhales  is  fetid.     This  affection  travels  rapidly  and 

twelve  parts  of.  water,  allow  the  liquor  to  settle  for  three  hours  in  close  vessels, 
filter  and  wash  the  dregs  with  two  parts  more  of  water.  Dissolve  with  a  gentle 
heat  two  parts  of  crystals  of  subcarbonate  of  soda  in  four  parts  of  water,  and  let 
the  solution  cool.  Then  mix  and  stir  the  two  solutions  well.  A  copious  pre- 
cipitate of  carbonate  of  lime  will  be  the  result,  and  the  liquor,  after  settling,  is 
decanted  or  filtered  and  bottled  up  tightly. — Journal  of  the  Philadelphia  CoU 
lege  of  Pharmacy ,  Vol.  J.  p.  218.— Translator. 


Gangrene.  53 

exercises  a  particular  influence  upon  the  brain  and  nervous  sys- 
tem, so  as  to  produce  there  an  ataxia,  while  the  hospital  gan- 
grene confines  its  operation  to  the  fibrous  and  serous  apparatus 
of  the  organs  of  internal  life,  in  which  case  those  of  the  life  of 
relation  remain  unmolested. 

The  causes  of  this  mortal  affection  are  the  attrition  and  com- 
motion of  the  parts  which  have  been  seized  with  it:  the  former 
of  these  may  at  the  moment  of  the  occurrence  produce  a  slough 
which  cannot  be  mistaken  for  the  gangrene,  properly  so  called, 
the  result  of  which,  however,  is  the  same;  but  shortly  after, 
this  eschar  of  attrition  is  detached;  the  swelling  which  appeared 
at  first  is  scattered,  and  the  surrounding  parts  which  were  the 
seat  of  it,  return  to  their  primitive  integrity.  In  gangrene 
proper,  however,  the  swelling  increases  successively,  till  the 
disorganization  of  the  tissues  is  accomplished,  of  which  it  spares 
none;  the  epidermis  is  converted  into  vesications  (phlyctense); 
the  dermis  turns  black,  is  dried  up  or  decomposed;  the  cellular 
texture,  the  aponeuroses,  muscles,  nerves,  and  blood  vessels  are 
alike  attacked  by  this  mortification,  and  are  involved  together 
in  the  disorganized  mass;  the  fluids  coagulate  within  their  ves- 
sels above  the  point  of  disorganization,  especially  in  the  dry 
gangrene,  or  gangrene  from  frost-bite,  which  presents  some 
differences  from  that  which  occupies  us  at  present. 

If  a  portion  only  of  the  external  organs  has  been  attacked  by 
it,  it  is  designated  by  the  name  of  partial  gangrene;  if  it  attacks 
the  totality  of  a  limb,  it  is  then  characteristic  of  sphacelus, 
which  will  be  more  fully  spoken  of  under  the  head  of  amputa- 
tions. 

A  gangrenous  affection  may  be  induced  by  a  sickly  habit  of 
the  patient:  thus  the  yellow  fever,  during  our  expedition  in 
Egypt,  caused  it  to  be  developed  in  the  wounds  of  all  those 
who  had  been  attacked  by  that  fever,  even  in  cases  of  the  most 
simple  wounds,  as  those  made  by  side  arms. 

This  complication  never  requires  the  actual  cautery,  as  re- 
commended by  some  writers,  notwithstanding  its  efficacy  in 
hospital  gangrene.  So  far  from  arresting  the  progress  of  gan- 
grene, this  caustic  increases  the  disorganization  of  the  tissues 
and  propagates  the  deleterious  action  of  the  disease.  When  it 
is  merely  local,  its  separation  may  be  facilitated  by  means  of 


54  Tetanus. 

anodyne  emollient  applications  to  the  periphery  of  the  sloughs, 
the  whole  of  which,or  as  much  of  them  as  is  practicable,  should 
be  removed  afterwards  with  a  cutting  instrument,  and  the 
wounds  dressed  with  mild  antiseptics,  the  base  of  which  should 
be  camphor.  In  case  the  disorder  should  have  been  ushered 
in,  established  or  kept  up  by  some  fever  of  a  bad  character,  it 
is  necessary  first  to  subdue  the  exciting  cause,  or  to  go  on,  at 
least,  with  the  remedies  which  are  best  suited  to  weaken  its 
force. 

Finally,  under  some  circumstances,  gangrene  is  a  healthy 
effort  of  nature,  in  so  far  as  she  concentrates  towards  the  point 
of  disorganization,  the  effects  of  the  erethismus  and  stupor 
which  far  and  wide  benumb  the  parts,  and  cause  the  traumatic 
fever  to  be  developed,  the  consequences  of  which,  frequently 
and  in  preference,  have  a  tendency  to  attack  the  brain  and 
nervous  system. 

Of  Tetanus. 

Of  all  the  complaints  attendant  upon  wounds,  particularly 
those  from  fire  arms,  tetanus  is,  without  fear  of  contradiction, 
the  most  serious,  and  consequently  merits  our  utmost  attention. 

It  comes  on  with  dull  pains  in  the  wound,  the  suppuration 
of  which  is  speedily  diminished  and  finally  suppressed  alto- 
gether. The  skin  becomes  bloated  and  dries  up;  it  is  red  at 
first,  and  afterwards  spotted.  The  local  pains  soon  increase 
and  seem  to  extend  along  the  passage  of  the  nerves  which 
are  in  connexion  with  the  wound;  and  the  contact  with  a 
cold  or  moist  air,  or  the  touch  of  the  lightest  external  bodies 
are  sufiicient  afterwards  to  occasion  them  or  to  impart  to  them 
a  higher  degree  of  intensity;  at  last  the  muscles  become  subject 
to  convulsive  contractions,  accompanied  or  preceded  by  violent 
cramps  and  subsultus  tendinum. 

Various  modifications  of  tetanus  have  been  admitted  to  exist, 
according  to  the  regions  of  the  body,  where  the  contractions 
are  developed  and  more  particularly  settled,  and  according  to 
the  acute  or  chronic  character  of  the  disease;  every  one  of  these 
modifications  presents  remarkable  differences. 

Sometimes  the  irritation  rapidly  extends  from  the  muscles 
in  the  vicinity  of  the  wound  to  the  more  remote  ones,  which 


Tetanus.  55 

become  stiff  and  contracted;  sometimes  it  is  suddenly  trans- 
ferred to  the  muscles  of  tlie  throat  and  jaws,  where  it  is  con- 
centrated; the  latter  gradually  approach  one  another  and  close 
in  such  a  manner  as  to  admit  of  little  or  no  separation.  De- 
glutition now  becomes  difficult,  and  soon  altogether  impossible, 
from  the  forcible  contraction  of  the  pharynx  and  œsophagus. 
The  trismus,  however,  as  it  arises  from  wounds,  rarely  exists 
by  itself,  but  is  commonly  one  of  the  effects  of  general  tetanus. 

When  this  affection  is  general,*  all  the  muscles,  external  and 
internal,  are  attacked  at  the  same  time.  Whilst  the  limbs 
contract  and  become  completely  straight,  and  whilst  the  whole 
body  grows  so  rigid  that,  by  seizing  one  of  his  extremities,  it 
may  be  lifted  up,  as  if  it  were  one  inflexible  mass;  the  other 
organs  of  the  animal  economy  lose,  from  the  same  cause,  the 
use  of  their  functions.  The  eyes  no  longer  retain  their  usual 
mobility;  they  sink  into  the  orbits  and  become  watery;  the 
face  colours;  the  mouth  becomes  contorted;  and  the  head 
is  in  various  ways  inclined,  according  to  the  particular  species 
of  tetanus.  The  walls  of  the  abdomen  approach  the  vertebral 
column  and  press  upon  the  contained  viscera  of  this  cavity, 
which,  on  their  part,  appear  to  bury  themselves  in  the  hy- 
pochondria, the  pelvis  and  the  iliac  fossae,  where  the  repeated 
contractions  of  the  muscles  pursue  them,  and  exercise  over 
them  a  more  or  less  powerful  degree  of  compression.  The 
ribs,  where  the  abdominal  muscles  are  inserted,  are  drawn 
downwards;  the  movements  of  the  diaphragm  become  restrict- 
ed; the  chest  sunk;  the  respiration  short  and  laborious;  the  heart 
contracts  more  and  more,  and  its  contractions,  which  become 
frequent  and  imperfect,  cannot  but  weaken  the  circulation  of  the 
blood.  The  patient  is  in  a  state  of  watchfulness,  and  when  he 
does  fall  asleep,  he  has  dismal  dreams;  he  is  restless,  uneasy; 
he  tosses  about  and  tries  to  rid  himself  of  the  state  of  constraint 
in  which  the  rigidity  of  his  limbs  and  the  inactive  state  of  his 
organs  keep  him. 

The  brain  alone  has  appeared  to  us,  in  this  universal  attack, 
constantly  to  maintain  the  integrity  of  its  functions,  even  to 

•  I  do  not  intend  here  to  speak  of  any  thing  else  but  of  traumatic  tetanus,  for 
the  spontaneous  oi  internal  tetanus  will  not  always  produce  the  same  results. 
Read  the  authors  who  have  written  on  this  species  of  disease. 


56  Tetanus. 

the  last  moment  of  existence;  so  that  the  unfortunate  indivi- 
dual who  is  affected  with  the  disease,  is  as  it  were  an  eye-wit- 
ness of  his  own  death.  However  that  may  be,  it  is  an  exceed- 
ingly curious  phenomenon  to  see  this  central  organ  of  the 
nervous  principle  remain  untouched,  whilst  all  the  nerves,  even 
those  of  the  life  of  relation,  are  so  deeply  injured.  Still,  there 
is  no  denying  the  fact,  for  in  the  great  majority  of  persons  at- 
tacked with  traumatic  tetanus,  whom  I  have  been  called  upon  to 
treat,  I  have  never  seen  the  intellectual  functions  disordered,  or 
the  senses  materially  changed.  Nay,  this  circumstance  amounts 
to  the  surest  diagnostic  between  tetanus  and  the  convulsive  or 
spasmodic  diseases,  arising  from  lesion  of  the  brain.  I  shall 
not,  however,  venture  any  explanation  concerning  the  want 
of  communication  of  the  morbid  principle  of  the  affected  nerves 
with  the  encephalon;  for  it  vvill  always  prove  that  the  ner- 
vous cords  are  not  by  any  means,  as  has  been  believed,  real 
elongations  of  that  organ. 

All  the  above  symptoms  make  such  rapid  strides,  that 
very  frequently  within  twenty-four  hours  the  patient  can 
swallow  no  longer,  or  swallows  only  with  the  greatest  dif- 
ficulty, though  at  the  same  time  he  experiences  the  utmost  de- 
sire to  drink  and  even  to  eat.  The  latter  imperious  necessity 
contributes  not  a  little  to  the  aggravation  of  the  complaint,  and 
it  may  be  asserted  that  the  majority  of  tetanic  patients  die  of 
hunger.  His  pulse  is  small  and  hurried;  some  febrile  action, 
followed  by  partial  and  more  or  less  copious  sweats,  generally 
comes  on  towards  evening.  He  declines  perceptibly  and  suffers 
excruciating  pains.  The  rigidity  increases,  the  muscles  may 
be  traced  distinctly,  and  the  skin  adheres  closely  to  their  peri- 
phery. The  salivary  glands  pour  out  a  frothy  and  whitish  se- 
cretion, which  may  be  seen  flowing  involuntarily  from  the 
patient's  mouth;  deglutition  is  also  interrupted.  It  is  at  this 
period  that  the  patient  becomes  aware  of  the  danger  in  which 
he  is,  and  that,  as  we  have  already  observed,  without  losing 
the  use  of  his  moral  faculties,  he  wretchedly  terminates  his 
career  on  the  third,  fourth,  fifth  or  seventh  day;  he  rarely  sur- 
vives to  the  seventeenth. 

In  emprosthotonos  the  flexor  muscles  prevail  over  the  ex- 
tensors, so  as  to  incline  the  head  against  the  trunk,  the  pelvis 


Tetanus. — Palkology.  57 

against  the  thorax;  and  the  body  thus  assumes  the  shape  of  an 
arch. 

In  opisthotonos,  on  the  contrary,  the  extensor  muscles  ex- 
ceed the  power  of  the  flexorsj  the  head  is  thrown  backwards  and 
the  vertebral  column  is  reversed  in  the  same  way;  the  limbs  re- 
main usually  extended.  This  kind  of  affection  is  more  rare 
than  emprosthotonos;  and  I  have,  moreover,  observed  that  it 
was  more  promptly  followed  by  death.  It  would  appear  that 
the  forcible  extension  of  the  cervical  vertebrae  and  the  unnatu- 
ral position  of  the  head  occasion  in  this  case,  more  than  in  the 
other  tetanic  modifications,  a  violent  compression  of  the  spinal 
marrow,  and  thereby  confirm  the  more  permanent  contraction 
of  the  larynx  and  pharynx.  I  have  remarked,  where  traumatic 
tetanus  has  been  produced  by  wounds,  in  which  the  nerves  of 
the  anterior  region  of  the  body  have  been  injured,  that  em- 
prosthotonos has  been  the  result  of  it  ;  but  that  opisthotonos 
will  take  place,  when  the  nerves  of  the  posterior  region  have 
received  the  injury;  and  finally,  when  the  offending  cause  has 
traversed  a  limb  in  such  a  manner  as  to  attack  equally  both 
these  two  nervous  expansions,  that  universal  tetanus  will  be 
established  by  throwing  the  individual  into  a  perfectly  straight 
position. 

When  this  disease  has  arrived  at  its  highest  stage,  as  well  as 
in  those  cases  where  it  is  influenced  by  some  one  or  other  of 
the  causes  which  determine  it,  as  cold  for  example,  we  may 
be  further  enabled  to  observe  several  peculiar  symptoms. 
The  patients  frequently  evince  an  extreme  aversion  for  liquids, 
so  that  when  compelled  to  swallow  them,  they  are  immediately 
seized  with  the  most  violent  convulsions.  This  phenomenon 
was  more  particularly  noticed  in  the  case  of  M.  Navailh,  a 
health-officer  of  the  second  class,  who  died  in  E^ypt  of  tris- 
mus, brought  on  by  a  wound  which  he  had  received  in  the 
face,  and  which  was  combined  with  a  comminuted  fracture  of 
the  bones  of  the  nose  and  of  a  portion  of  the  left  orbit.  Under 
the  circumstances  just  related,  the  irritation  which  is  trans- 
mitted by  the  wound  to  the  nervous  system,  is  doubtless  aug- 
mented by  the  suppression  of  the  cutaneous  perspiration,  which 
irritation  extends  its  effects  over  the  external  organs,  and 
H 


58  Tetanus. — Pathology. 

principally  over  the  parts  already  affected;  but,  generally,  the 
irritation,  from  the  first  attack  of  the  disease,  or  during  its 
progress,  is  altogether  concentrated  in  the  nerves  of  the  neck 
and  throat.  Their  immediate  connexion  with  the  spinal  mar- 
row, their  numerous  interlacings  and  frequent  anastomoses, 
render  them  susceptible,  after  the  slightest  impressions,  of  a 
very  high  degree  of  irritation,  which  at  once  determines  the 
contraction  of  the  muscles  of  these  regions,  in  such  a  manner 
that  deglutition  and  respiration  become  thus  forthwith  derang- 
ed. The  patients  manifest  afterwards,  if  not  a  horror,  at 
least  an  extreme  z-epugnance  for  liquids,  which  often  im- 
pedes the  employment  of  internal  remedies;  and  when  the 
wound  is  beyond  the  reach  of  medical  assistance,  the  individ- 
ual is  condemned  to  suffer  all  the  pains  which  that  cruel  and 
dreadful  disease  inflicts.  There  is  nothing  whereby  the  ob- 
stacles which  obstruct  the  passage  of  the  alimentary  canal 
can  be  removed.  The  introduction,  through  the  nose,  of  the 
gum  elastic  catheter  into  the  œsophagus,  is  attended  by  con- 
vulsions and  suffocation.  I  have  had  occasion  to  try  this  ex- 
pedient in  the  person  of  M.  Navailh  and  other  individuals. 
Upon  opening  the  bodies  of  persons  who  had  died  of  trismus,  I 
have  found  the  pharynx  and  œsophagus  considerably  contract- 
ed, their  lining  membranes  red,  inflamed,  and  Coated  with  a 
viscid  and  reddish  secretion. 

Hydrophobia,  hysteria,  and  several  other  nervous  diseases 
equally  direct  their  principal  effects  to  these  organs,  and  their 
results  frequently  appear  to  be  the  same.  I  shall  not,  how- 
ever, indulge  in  any  remarks  upon  the  analogy  of  symptoms 
which  these  different  diseases  present. 

In  every  instance,  one  of  the  most  constant  and  most  severe 
effects  of  the  causes  which  produce  tetanus,  or  of  tetanus  itself, 
is  to  induce  a  more  or  less  extensive  phlegmasia,  first,  in  the 
spinal  marrow  and  nervous  system  of  relation,  and  subsequently 
in  that  of  the  nerves  of  organic  life,  through  the  medium  of 
the  sympathetic  and  direct  connexions  which  exist  to  a  great 
extent  between  the  two  systems.  But  still,  the  proximate 
cause  of  death,  at  the  termination  of  the  various  tetanic  affec 
tions,  must  not  be  referred  to  these  spinal  and  nervous  inflam- 
mations alone,  but  more  particularly  to  the  powerful  compress- 


Tetanus. —  Causes.  59 

ion  of  the  abdominal  viscera,  to  the  constraint  which  the  organs 
of  respiration  are  subjected  to,  to  the  contracted  state  of  the 
heart,  and  in  the  last  place  to  the  engorgement  ofthe  spinal  and 
cerebral  membranes.  A  sufficiently  large  number  of  autopsical 
examinations  which,  with  the  utmost  care,  we  have  ourselves 
instituted  in  different  countries,  but  especially  in  the  hospitals 
of  Louvaiu;  after  the  battle  of  Waterloo,  of  individuals  whom 
we  had  caused  to  be  dressed  under  our  own  eyes,  and  who 
afterwards  perished  from  tetanus,  have  invariably  presented  to 
us  well-marked  vestiges  of  inflammation  in  the  spinal  marrow, 
with  a  more  or  less  perceptible  effusion  of  a  reddish  serum  in 
the  vertebral  column.  Now,  as  this  species  of  phlegmasia, 
when  once  established,  aggravates  the  symptoms,  rapidly  pro- 
motes their  progress  and  would  necessarily  render  them  mor- 
tal, it  is  therefore  a  highly  important  matter  to  endeavour  to 
remove  it,  whilst  at  the  same  time,  the  traumatic  cause  itself 
should  be  attacked  by  forthwith  applying  to  the  vertebral  co- 
lumn, the  proper  depleting  revulsives. 

After  having  given  a  detailed  description  of  the  symptoms 
by  which  tetanus  is  characterized,  and  of  the  general  sympa- 
thetic phenomena  which  they  may  occasion,  we  now  propose 
to  give  an  account  of  the  numerous  causes  which  are  the  sub- 
ject of  its  formation,  as  well  as  of  the  influences  which  the  dif- 
ference of  climate  exercises  in  this  disease. 

To  the  principal  causes  of  tetanus  necessarily  belong 
gun-shot  wounds,  particularly  at  the  ginglymoid  articulations, 
or  at  the  passage  of  nerves;  comminuted  fractures;  the  pre- 
sence of  foreign  bodies  which  have  been  introduced  or  de- 
veloped, and  which  puncture  or  lacerate  the  tissues;  the  violent 
separation  of  tendons,  ligaments,  nerves  and  blood-vessels;  the 
more  or  less  considerable  loss  of  substance  in  the  soft  parts,  or 
in  the  whole  thickness  ofthe  limb,  so  as  to  tear  and  expose  a 
large  number  of  nervous  filaments,  which  is  done,  for  example, 
by  the  larger  projectiles,  by  biscayans,  by  the  bursting  of  bombs, 
or  cannon  balls. 

The  ligature  of  the  nerves,  and  particularly  of  their  princi- 
pal cords;  the  too  sudden  impression  which,  at  the  moment  of 
the  separation  of  the  sloughs,  they  may  receive  by  coming  in 
contact  with  the  cold  and  moist  air;  the  too  close  adhesions 


60  l^elan  as.  —  Causes. 

which  they  may  form  with  the  corresponding  points  of  the 
cicatrix,  are  also  powerful  agents,  well  calculated  to  give 
rise  to  tetanus,  to  which  the  undivided  attention  of  the  practi- 
tioner should  be  directed,  especially  as  they  may  begin  to  ope- 
rate at  the  moment  when  it  could  be  least  expected,  and  when 
the  patient  was  believed  to  be  out  of  danger. 

Tetanus  makes  its  appearance  more  generally  in  young  sub- 
jects, and  sometimes  even  upon  occasion  of  the  most  trifling 
wounds,  of  which  we  have  seen  frequent  instances,  in  Egypt; 
but  in  this  climate,  the  moisture  and  the  sudden  change  of 
temperature  appear  to  be  the  chief  promoters  of  it.  This  may 
also  depend  upon  the  physical  or  moral  disposition  in  which  the 
patient  finds  himself,  or  upon  other  supervening  causes.  1 
have,  besides,  observed,  that  this  complaint  does  not  commonly 
show  itself  in  the  wounded,  although  the  essential  cause  should 
almost  always  be  the  same,  except  during  the  seasons  when 
the  temperature  suddenly  changes  from  one  extreme  to  another. 
The  wounded  who  expose  themselves,  through  the  night,  to  the 
immediate  influence  of  the  cold  and  humid  air  which  the  north- 
west winds,  especially  in  the  spring,  so  constantly  produce, 
are  very  apt  to  contract  tetanus,  whilst  this  complaint,  on  the 
contrary,  but  seldom  breaks  out,  when  the  temperature  is 
nearly  equal,  in  summer  and  in  the  winter  season.  We  may, 
therefore,  come  to  the  conclusion  that  contact  with  this  nox- 
ious air,  is,  to  say  the  least,  one  of  the  exciting  causes  of 
the  tetanic  afiection,  which  ought  to  put  surgeons  on  their 
guard,  and  enjoin  upon  them  that,  in  the  treatment  and  dress- 
ing of  wounds,  in  those  two  seasons,  it  is  of  the  greatest  con- 
sequence to  do  it  with  the  utmost  care  and  gentleness. 

The  suppression  and  repulsion  of  the  purulent  secretion  of 
the  wound,  as  well  as  that  of  the  cutaneous  perspiration  are  the 
first  immediate  effects  of  these  sudden  transitions  from  heat  to 
cold;  and  these  effects  may  the  more  readily  excite  tetanus  in 
proportion  as  they  themselves  come  on  more  rapidly,  and 
as  the  atmospheric  phenomena  have  exhibited  a  more  or  less 
sudden  and  decided  deviation.  Indeed,  the  wounded  who 
during  the  Austrian  campaign,  in  1809,  had  sustained  divers 
degrees  of  excessive  heat  through  the  day,  and  were  the  most 
exposed  to  the  action  of  the  cold  and  humid  air  of  the  freez- 


I 


Tetanus. — Modifications.  6 1 

îng  nights  of  spring,  were  almost  all  attacked  by  this  dis- 
ease which  only  prevailed  during  that  season,  in  the  course  of 
which  the  thermometer  of  Reaumur  varied  almost  constantly 
from  day  to  night,  by  half  of  its  rise  and  fall  ;  thus,  we  had 
in  the  middle  of  the  day,  19,  20,  21,  and  23  degrees  above 
zero,  whilst  the  mercury  fell  down  to  13,  12,  10,  9,  and  8  at 
night.  The  same  variations  have  been  equally  well  marked 
in  Egypt. 

With  the  causes  just  enumerated,  there  is  a  verminous  af- 
fection sometimes  associated,  which  cannot,  however,  prove 
dangerous  by  itself;  for,  at  the  opening  of  several  corpses,  we 
have  found  a  pretty  large  quantity  of  lumbricoid  worms  which 
had  left  no  trace  whatever  of  inflammation  in  the  intestines. 

Modifications  of  which  the  symptoms,  accompanying  teta- 
nus, are  susceptible  from  a  diversity  of  climate,  must  certainly 
be  allowed  to  exist;  nevertheless,  these  modifications  are  less 
perceptible  than  might  be  supposed,  and  I  may  assert  that  in 
the  different  countries  over  which  I  have  travelled,  the  symp- 
toms of  tetanus  have  nearly  every  where  presented  to  me  the 
same  analogy.  That  which  prevailed  in  Egypt,  has,  generally 
speaking,  appeared  to  me  to  be  more  intense  and  to  resemble 
much  more  the  attacks  of  hydrophobia.  I  have,  moreover, 
noticed  that  in  that  country,  gun-shot  wounds  at  the  passage  of 
the  nerves,  or  at  the  articulations,  have  produced  it  more  fre- 
quently than  any  where  else,  particularly  during  the  seasons 
which  are  so  extremely  changeable,  in  consequence  of  their 
temperature  in  damp  districts  and  those  bordering  on  the  Nile, 
and  on  the  sea.  Dry  and  irritable  temperaments  have  been  in 
Egypt  the  most  exposed  to  this  complaint,  and  finally  its  ter- 
mination there  has  been  generally  fatal. 

Amongst  the  number  of  the  wounded,  after  the  battle  of  the 
Pyramids,  there  were  five  attacked  with  tetanus,  in  whom  it 
was  doubtless  developed  by  the  dampness  and  coolness  of  the 
nights.  It  resisted  the  continued  and  varied  exhibition  of  an- 
tispasmodics combined  with  narcotics,  and  taken  in  large  doses; 
all  of  them  perished  on  the  third,  fourth,  or  fifth  day.  Their 
death  was  preceded  by  copious  sweats. 

At  the  insurrection  of  Cairo,  on  the  21st  October  1798,  the 


€2  Tetanus. — Modifications. 

wounded  were  received  into  the  hospital,  at  the  square  of  Bir- 
ket-el-Fyl,  the  walls  of  which  were  washed  by  the  waters  of  the 
Nile,  which  is  stationary  there  for  three  months  in  the  year. 
Seven  of  their  number  were  seized  with  tetanus,  by  which 
they  were  destroyed  in  a  very  few  days,  in  spite  of  the  continu- 
ed administration  of  opiates,  of  baths  of  tepid  water  for  some, 
and  of  cold  water  for  others.  Amongst  four  of  them,  it  was 
characterized  by  emprosthotonos;  two  died  of  general  tetanus, 
and  the  seventh  of  locked  jaw.  The  whole  injury  of  the  latter 
amounted  only  to  a  simple  division  of  the  pinna  of  the  right 
ear,  which  was  caused  by  a  shot.  If  that  portion  had  been  cut 
off,  when  the  first  symptoms  began  to  show  themselves,  the 
life  of  the  patient  would  probably  have  been  saved. 

After  the  engagement  of  El-Arich,  the  wounded  were  ac- 
commodated under  tents  on  a  damp  ground,  and  exposed  to  the 
perpetual  rains  which  we  had  to  endure,  during  the  siege  of 
that  fortress.  Eight  were  attacked  with  tetanus  which  appear- 
ed in  all  its  gradations  and  terminated  in  all  of  them  fatally, 
from  the  fifth  to  the  seventh  day  after  the  attack,  notwithstand- 
ing the  attentions  which  the  nature  of  the  circumstances  per- 
mitted us  to  bestow  upon  them. 

At  the  taking  of  Jaffa,  we  lost  several  wounded  in  conse- 
quence of  tetanus  of  an  extremely  acute  degree.  All  those 
who  were  seized  with  it  died  in  two  or  three  days.  The  moxa 
and  the  alkalies,  which  were  employed  in  several  instances, 
seemed  to  aggravate  the  symptoms.  It  must  be  observed,  how- 
ever, that  the  hospitals  were  situated  on  the  sea-shore,  and  that 
the  season  was  wet. 

From  the  number  and  known  intensity  of  the  symptoms 
which  the  disease,  under  discussion,  originates;  from  the  per- 
nicious and  almost  indestructible  influence  of  its  primary  or 
secondary  causes,  we  may  easily  account  for  the  resistance 
which  this  affection  offers  to  our  therapeutic  means,  and  for  the 
rapidity  with  which  it  hurries  the  individuals  attacked  by 
it,  towards  a  fatal  catastrophe.  Experience  has,  indeed,  fur- 
nished us  with  the  most  convincing  proofs,  that  when  tetanus 
is  left  to  the  sole  resources  of  nature,  or  when  it  is  encounter- 
ed with  a  medicine  which  is  almost  inactive,  the  patients  are 


Tetanus. —  Tt^eatment.  6S 

quickly  destroyed.  The  medical  man,  therefore,  without  loss 
of  time,  ought  to  fulfil,  as  far  as  possible,  all  the  indications 
which  this  disease  presents. 

Having  been  placed,  during  thirty  years,  in  circumstances 
the  most  favourable  for  seeing  and  observing  frequently  this 
baneful  affection, — instructed  in  the  true  causes  of  tetanus  and 
the  pathological  phenomena  which  it  developes,  especially  in 
the  nervous  system,  it  has  been  less  difficult  for  me  to  conduct 
the  treatment  of  it.  Thus,  I  have  met  with  great  success  from 
the  employment  of  several  remedies  suggested  to  me  by  the 
knowledge  of  those  nervous  pathological  phenomena,  which  I 
have  had  such  frequent  opportunities  to  acquire  and  confirm 
after  death.  By  administering,  upon  the  first  appearance  of 
the  symptoms  of  tetanus,  the  remedies  which  I  have  deemed 
most  suitable  to  subdue  the  causes  which  produce  it,  I  have 
often  succeeded  in  removing  at  once  the  incidental  events  which 
were  about  to  appear. 

In  those  cases  where  a  nerve  had  been  included  within  the 
ligature  of  an  artery,*  the  division  of  that  ligature  (which  the 
wounded  signalized  as  the  continued  seat  of  pain,  and  from 
whence  the  nervous  irritation  seemed  to  originate)  caused 
the  suspension  of  the  disease,  and  accelerated  the  healing  of 
the  wound.     There  is  no  hemorrhage  to  be  apprehended,  pro- 

•  Although  several  commendable  authors  and  a  great  many  practitioners  are 
DO  ways  afraid  of  the  effects  of  a  ligature  upon  the  nerves,  when  they  tie  the 
neighbouring  arteries,  after  the  operation  for  amputation  or  aneurism,  I  am 
nevertheless  convinced  of  its  possible  danger,  according  to  the  manner  in  which 
it  is  done,  or  according  to  some  unforeseen  incidents  which  may  accompany  it. 
As  to  the  ligature  itself,  if  it  be  not  drawn  so  tight  as  entirely  to  suspend  in  the 
nerve  the  passage  of  the  nervous  fluid,  I  have  constantly  remarked  some  casu- 
alties to  supervene.  In  case  even  where  the  nerve  is  completely  strangulated, 
when  the  parts  begin  to  swell  beyond  the  ordinary  degree,  these  symptoms  may 
come  on  in  consequence  of  the  disturbance  which  the  nerve  experiences  above 
the  tied  point.  It  is  therefore  somewhat  diflBcult  to  meet  with  a  sufficiently 
favourable  circumstance  where  such  a  ligature  could  be  applied  without  oc- 
casioning any  inconvenience  whatever,  were  it  only  the  acute  pain  of  the 
moment.  After  this  it  will  be  piudent  and  wise,  to  avoid,  as  much  as  possible, 
the  ligature  of  the  nervous  cords,  and  particularly  so  in  climates  propitious  to  the 
development  of  tetanus.  If  the  circumstances  should  not  permit  to  avoid  it 
altogether,  it  ought  to  be  drawn  sufficiently  tight,  so  as  to  operate  as  a  complete 
conslriction  upon  the  nerves. 


64  Teianus.  —  Treatment. 

vided  that  the  vital  powers  have  not  l>een  weakened,  and  that 
there  is  no  kind  of  disposition  to  a  state  of  adynamia;  a  few 
hours  of  immediate  compression  made  upon  an  artery,  till  its 
coats  touch  one  another,  often  suffice  to  establish  the  adhesive 
inflammation.  In  order  to  perform  this  otherwise  pretty  deli- 
cate operation,  a  grooved  director  is  to  be  insinuated  between 
the  artery  and  the  loop,  after  which  a  thin  and  narrow  scissar 
blade  may  be  passed  along  its  groove  for  the  purpose  of  cut- 
ting the  cord.  On  five  individuals  I  have  had  occasion  to  feel 
justified  to  perform  this  operation,  some  of  whom  were  threat- 
ened with  tetanus,  whilst  in  the  others  the  ligature  had  become 
identified  with  the  cicatrix,  so  as  to  remain  there  probably 
for  life,  of  which  I  have  seen  several  examples,  and  which  is 
not  only  troublesome,  but  even  dangerous,  because  it  may  be 
torn  off  by  unforeseen  causes. 

When  I  suspected  the  nerves  to  be  pinched,  either  by  the 
increase  of  volume  of  the  neighbouring  blood-vessels,  or  by  the 
adhesion  of  several  points  of  the  cicatrix,  I  never  hesitated 
for  a  moment  to  apply  the  actual  cautery  to  such  a  depth,  as 
was  necessary  in  order  to  reach  the  injured  points  of  these 
nerves,  and  if  possible  even  beyond  them.  This  remedy,  so 
deservedly  valued  by  the  physicians  of  ancient  times,  has  per- 
formed miracles.  By  destroying  the  nervous  adhesions  and 
the  twitches  which  resulted  from  them,  it  caused  the  cessation 
of  the  spasm  and  irritation.  It  is  possible  that  the  share  of 
absorbed  caloric  may  have  a  tendency  to  remove  the  numbness 
into  which  the  chilling  moisture  appears  to  throw  the  nervous 
system. 

There  are  besides  other  essential  and  more  general  indica- 
tions than  those  of  which  I  have  just  been  speaking,  which  pre- 
sent themselves,  and  require  subsequently  to  be  fulfilled  in  a 
great  many  instances.  They  consist  in  the  removal  of  the 
causes  of  irritation  and  in  the  re-establishment  of  the  suppressed 
secretions. 

The  first  of  these  indications  may  be  accomplished  by  en- 
largements, or  seasonable  incisions,  made  at  the  wound,  before 
the  symptoms  of  inflammation  have  become  manifest;  for  if  the 
latter  should  already  have  advanced,  such  incisions  would  then 


Tetanus.  —  Treatment.  65 

be  useless  and  even  dangerous.  They  must  include,  as  much 
as  possible,  all  the  nervous  cords  and  membranous  portions 
which  are  injured  by  the  offending  cause. 

Caustic  applications  to  the  wound  may  be  made  with  advan- 
tage, at  the  time  when  the  first  symptoms  show  themselves, 
provided  the  same  rule  be  adopted  for  their  employment  which 
is  laid  down  for  that  of  making  incisions.  These  operations 
should  be  followed  up  by  venesection,  if  it  can  be  done,  and 
by  the  use  of  emollient  and  anodyne  local  measures,  although 
their  effects  are  generally  very  feeble.  And,  in  order  to  pre- 
vent or  disperse  the  inflammation  of  the  spinal  marrow  which 
we  have  stated  to  be  one  of  the  leading  consequences  of  tetanus, 
and  in  some  cases  an  important  and  predisposing  cause  of  this 
disease,  scarified  cups  should  be  applied  simultaneously  and 
repeatedly  to  both  sides  of  the  vertebral  column.  These  may 
most  advantageously  be  succeeded,  as  soon  as  the  sanguineous 
depletion  shall  have  been  sufiicient,  by  the  application  of  the 
moxa,  two  by  two  placed  upon  the  same  spots  after  the  method 
pursued  by  us.  The  application  of  this  topical  revulsive  is  to  be 
repeated  according  to  the  consecutive  effects  of  the  inflamma- 
tion. It  will  be  serviceable  to  allow  the  burns  to  go  on  to 
suppuration. 

The  second  indication  also  may  be  successfully  accomplished 
by  a  variety  of  means.  There  are  the  suppurative  epispastics, 
which  are  prepared  by  sprinkling  upon  a  pledget,  spread  with 
some  camphorated  balsamic  substance,  a  proportionate  quantity 
of  cantharides  which  previously  must  have  been  reduced  to 
powder  and  exposed  to  the  steam  of  boiling  water  ;  these  epis- 
pastics when  applied  to  wounds,  the  suppuration  of  which  is 
diminished,  and  the  nerves  of  which,  after  having  been  laid  bare, 
have  been  irritated  by  the  contact  with  the  cold  and  moist  air, 
prevent  and  mitigate  the  effects  of  tetanus.  Being  employed 
upon  the  appearance  of  the  first  symptoms,  these  remedies  re- 
store the  diseased  nervous  cords  to  their  natural  sensibility  and 
reproduce  the  purulent  secretions.  At  the  same  time  the  cu- 
taneous perspiration  is  to  be  recalled  by  means  of  embrocations 
with  very  hot  camphorated  and  opiated  oil  of  chamomile.  The 
effects  of  the  latter  may  be  promoted  by  diaphoretic  and  alka- 
I 


66  Tetanus.  —  Treatment. 

line  drinks,  by  the  use  of  flannels,  and  by  anthelnmintics,  if 
there  should  be  reason  to  apprehend  the  existence  of  worms  in 
the  intestines.  All  these  remedies  have  alike  produced  happy 
effects,  if  the  exciting  cause  arose  from  cold. 

Internal  remedies,  whatever  may  be  their  properties,  are 
almost  always  useless  in  the  treatment  of  tetanus,  because  the 
patient,  soon  after  being  attacked  with  it,  falls  into  a  state  of 
strangulation;  nevertheless,  if  this  symptom  should  not  become 
developed  till  towards  the  end  of  the  disease,  and  by  degrees 
only,  those  remedies  may  be  employed,  upon  a  graduated  scale, 
in  which  practitioners  have  had  the  most  confidence,  such  as 
opium,  camphor,  musk,  castoreum  and  the  modified  alkaline 
medicines.  We  have  advantageously  made  use  of  the  above 
remedies,  especially  in  Egypt,  in  the  cases  of  some  patients 
whose  histories  we  intend  to  give  below.  Amongst  the  in- 
ternal beverages  which  may  be  given,  I  have  noticed  that  the 
patients  show  less  reluctance  to  swallow  emulsions  than  any 
other  liquids;  they  are  less  transparent  than  pure  water,  they 
are  sweeter  and  more  agreeable,  and  promote  the  effect  of  the 
remedies  with  which  they  may  be  combined. 

In  important  wounds  of  the  extremities,  with  considerable 
and  more  or  less  irregular  loss  of  substance,  in  those  which  are 
accompanied  with  shattering  of  the  bones  and  a  disorganized 
condition  of  the  tissues,  and  in  short,  in  all  those  which  de- 
mand the  amputation  of  the  wounded  limb,  this  operation, 
under  such  circumstances,  and  in  order  to  avoid  numerous  mis- 
haps, is  not  only  indispensable,  but  has  proved  by  experience 
to  be  also  the  surest  remedy  by  far  to  avert  the  tetanic  affec- 
tion. An  event  as  happy  as  it  was  unexpected,  has  even 
drawn  my  attention  to  the  extraordinary  therapeutic  influence 
of  this  operation  during  the  existence  of  that  very  disease;  this 
is  the  complete  success  in  the  treatment  of  a  case  of  tetanus 
which  chance  procured  for  me  in  Egypt,  after  the  amputation 
of  a  wounded  limb,  in  the  person  of  an  ofiicer  who  had  been 
attacked  by  this  affection  in  its  chronic  form,  a  result  which 
induces  me  to' propose  the  following  query: 

"When  tetanus  is  caused  by  a  wound  whereby  some  part  of 


Tetanus.  —  Treatment.  67 

the  extremities  has  been  injured,  the  wound,  however,  not 
being  sufficiently  serious  to  require  an  amputation,  would 
it  not  be  better  to  take  ofi'  the  extremity  by  means  of  this 
operation,  at  the  moment  when  the  symptoms  are  about  to 
appear,  than  to  depend  upon  the  resources  of  nature  and 
upon  uncertain  remedies  for  the  cure  which  so  seldom  takes 
place  spontaneously?'' 

Without  presuming  to  solve  the  important  question  which 
has  just  been  proposed  by  me,  I  may  yet  be  permitted  to  ven- 
ture to  produce  some  reasons  which  appear  to  me  to  militate  in 
favour  of  the  amputation. 

As  soon  as  it  is  clearly  ascertained  that  tetanus  has  been 
induced  by  the  wound,  there  can  be  no  longer  any  doubt  about 
performing  this  operation,  at  the  moment  of  the  appearance  of 
the  symptoms.  That  it  is  traumatic  may  be  learned  from  the 
nature  of  the  wound;  from  the  progress  of  the  first  symptoms, 
and  from  the  consideration  of  the  period  of  their  invasion  which 
takes  place  from  the  fifth  to  the  fifteenth  day,  at  farthest.  It 
would  seem  that  this  is  the  moment  when  the  nervous  irrita- 
bility is  very  great.  When  the  process  of  suppuration  has 
commenced,  when  the  stupor  is  speedily  relieved,  the  vessels 
unload  themselves,  the  sloughs  separate,  and  the  nerves  find 
themselves  in  a  state  of  perfect  ease;  then  their  sensibility  is 
extreme,  and  they  are  susceptible,  on  the  most  trifling  impress- 
ions, of  the  highest  degree  of  irritation,  which  quickly  com- 
municates itself  to  the  whole  nervous  system.  If,  under  such 
circumstances,  the  wound  is  acted  upon  by  a  cold  and  moist  air, 
or  if  some  foreign  body  should  happen  to  remain  there,  prick- 
ing the  nervous  parts  which  are  now  isolated  from  their  sloughs, 
tetanus  is  inevitable,  particularly  so  in  hot  climates.  This  dis- 
ease afterwards  may  be  expected  to  be  rapidly  on  the  increase, 
so  that  in  very  little  time  all  the  parts  of  the  limb  become  in- 
volved in  it  and  all  the  nerves  irritated.  The  effects  of  this  first 
cause  may  be  complicated,  also,  by  the  presence  of  worms  in 
the  intestines,  of  which  I  have  witnessed  an  instance  at  Nice; 
but,  by  watching  attentively  the  phenomena  of  tetanus,  the 
symptoms  which  characterize  these  less  important  complica- 


6S  Tetanus.  —  Treatment. 

tions  may  be  readily  distinguished  and  subdued  by  the  reme- 
dies indicated.* 

The  amputation  of  the  limb,  when  performed  during  the 
first  moments  after  the  appearance  of  the  symptoms,  suspends 
every  communication  of  the  source  of  the  complaint  with  the 
remainder  of  the  individual:  this  division  unloads  the  vessels, 
causes  the  cessation  of  the  nervous  twitches,  and  destroys  the 
convulsive  motion  of  the  muscles.  These  first  results  are 
followed  by  a  general  collapse  which  promotes  the  excretions 
and  sleep,  and  re-establishes  the  equilibrium  throughout  the 
whole  system.  The  amount  of  momentary  pain  which  is 
caused  by  the  operation  cannot  increase  the  existing  irritation; 
besides,  the  pains  of  tetanus  render  those  of  the  operation  more 
easy  to  be  borne,  and  diminish  their  intensity,  especially  when 
the  principal  nerves  of  the  limb  are  powerfully  compressed. 

The  great  wounds  with  or  without  loss  of  substance,  even 
those  which  are  the  result  of  amputation  of  a  limb,  though  they 
may  be  followed,  at  times,  by  a  tetanic  affection,  do  not  prove 
that  the  extreme  remedy  which  I  propose  for  this  disease  should 
be  dangerous,  or  that  it  should  not  be  attended  rather  with 
beneficial  results.  I  have  just  attempted  to  assign  my  reasons 
for  it.  When  tetanus  has  supervened  after  amputation  it  is 
certainly  not  this  operation  which  has  been  its  exciting  cause  ; 
agents  entire  strangers  to  it  have  simultaneously  operated 
and  through  their  sole  influence  directed  the  tetanic  pheno- 
mena, and  these  agents  which  we  have  already  pointed  out  as  the 
most  common  causes  of  this  disorder,  particularly  in  hot  cli- 
mates, have  been  the  action  of  a  cold  and  moist  air  upon  either 
accidental  or  surgical  wounds;  the  irritation  developed  by  the 
presence  of  foreign  bodies;  the  ligature  of  a  nerve  included  with- 
in that  of  an  artery;  and  finally  the  suspension  of  the  flow  of 
purulent  matter. 

In  those  instances,  otherwise  quite  rare,  of  amputations, 
where  a  tetanic  affection  has  been  observed  to  make  its  appear- 
ance, the  action  of  cold  or  of  a  ligature  upon  a  nerve  has  most 

*  The  sweet  and  fresh  oleum  ricini,  prepared  from  the  kernels  of  the  palma 
christi  of  America,  and  combined  with  a  few  grains  of  calomel,  is  the  most 
«impie  remedy  for  the  verminous  disorder. 


Tetanus.  —  Treatment.  69 

frequently  contributed  to  its  origin,  and  experience  as  well  as 
reasoning  have  taught  me  the  manner  in  which  those  causes 
operate  in  order  to  produce  this  disease.  Many  years  ago  I 
had  perceived  that  the  extreme  ends  of  tha  nerves,  divided  in 
the  amputation  of  the  limbs,  enlarged  considerably  and  formed 
each  a  kind  of  head,  from  which  filaments,  infinitely  fine  and 
divergent,  appeared  to  grow,  destined  no  doubt  to  transmit 
sensation  and  vital  action  to  the  cicatrix  of  the  stump,  which 
was  itself  composed  of  a  great  many  vessels  amongst  which 
those  small  filaments  have  appeared  to  me  to  become  lost.  At 
any  rate  the  existence  of  these  vesssls  has  been  demonstrated  by 
the  beautiful  injections  of  Doctor  Sœmmering.  Guided  by  this 
information  it  is  easy  to  form  an  idea  of  the  effects  of  cold  or 
other  sensible  changes  of  temperature  upon  the  thus  modified 
nervous  extremities,  and  consequently  to  explain  the  develop- 
ment of  tetanus.  If,  on  the  contrary  it  should  supervene  from 
the  constriction  of  a  nerve  by  ligature,  it  is  supposed  that  a 
spasmodic  action  is  then  about  to  be  established  which  spreads 
rapidly  from  the  extremity  of  the  divided  nerve  to  the  neigh- 
bouring ramifications,  thence  to  the  branches  and  successively 
to  the  trunks,  so  as  to  invade  the  whole  nervous  system,  with 
the  exception  of  the  brain,  as  we  have  had  occasion  already  to 
observe.  I  have  had  frequent  opportunities  to  convince  my- 
self of  the  exactness  of  the  physical  changes  which  are  brought 
about  in  the  nervous  extremities  which  have  been  divided  or 
compressed.  Upon  examination*  of  the  bodies  of  two  indi- 
viduals who  had  been  amputated  and  fallen  victims  to  the  con- 

•  The  same  phenomena  we  have  also  very  well  observed  in  the  son  of  Gene- 
ral Darmagnac,  a  young  officer  of  singular  courage  and  intelligence,  one  of  the 
wounded  at  the  battle  of  Eyiau,  and  in  whom  tetanus  terminated  fatally.  I  saw 
him  in  the  last  stage  of  the  disease  which  had  supervened,  after  the  amputation 
of  the  arm.  At  the  dissection  of  the  stump,  twenty-four  hours  after  death,  we, 
M.  Ribes  and  myself,  found  the  median  nerve  included  within  the  ligature  of 
the  artery.     The  extremity  of  this  nerve  was  tumefied  and  reddish. 

"  I  have  not  had  the  happiness  to  find  you  on  the  field  of  battle.  Monsieur  Larrey, 
said  the  young  warrior  to  me  ;  and  now  your  attentions  are  of  no  avail.  I  have 
terminated  this  glorious  career,  v/hich  I  had  scarcely  commenced.     Tell  my 

father  that  I  die  worthy  of  him,  and  convey  to  him  ray  last  farewell on 

the  brink  of  the  grave."  Whilst  uttering  these  last  words,  Darmagnac  made  an 
effort  to  turn  himself,  and  expired. 


70  Tetanus.  —  Treatment. 

sequences  of  tetanus,  during  the  Austrian  campaign,  we  noticed 
in  one  of  them,  whose  arm  had  heen  amputated,  the  median 
nerve  which  had  heen  included  within  the  ligature  of  the 
brachial  artery,  puffed  up  like  a  mushroom  below  the  ligature, 
and  much  swollen  above  it,  and  of  a  reddish  colour;  in  the 
other  who  had  been  amputated  nineteen  days  previously,  we 
likewise  noticed  the  nerves  puffed  up  at  their  extremities  and 
adhering  to  the  surrounding  parts.  These  states  of  nervous 
turgidity  have  already  been  met  with  by  several  anatomists. 

Finally,  however,  for  the  same  reason  for  which  under  ordi- 
nary circumstances  these  effects  ought  to  be  remedied,  it  will 
be  easy  for  an  attentive  surgeon,  after  he  may  have  decided 
upon  the  amputation  of  a  limb  for  the  purpose  of  curing  the 
tetanic  affection,  to  anticipate  and  prevent,  in  this  last  event, 
the  approach  or  influence  of  the  causes  which  we  have  just 
now  dwelt  upon.  This  object  may  be  attained  by  keeping  the 
wounded  in  a  temperature  sufficiently  warm,  and  as  far  as 
practicable,  always  equal;  by  taking  care  promptly  to  extract 
all  the  foreign  bodies,  to  dress  the  wound  gently,  to  cover  it 
forthwith  with  fine  and  perforated  linen,  and  not  to  takeoff  the 
first  dressing  of  recent  wounds,  till  suppuration  is  fairly  estab- 
lished and  even  then  as  late  as  possible.  Finally,  the  patient 
is  to  observe  a  strict  diet  and  the  most  absolute  rest. 

There  will  be  found  at  the  end  of  this  work,*  some  obser- 
vations on  the  success  attendant  upon  the  amputation  of  the 
wounded  limb  in  the  cure  of  tetanus,  and  on  the  care  with 
which  the  causes  ought  to  be  guarded  against,  which,  subse- 
quently to  that  operation,  might  result  in  a  new  tetanic  affec- 
tion. Although  I  must  regret  that  1  have  been  unable  to  exhibit 
a  larger  number  of  cures,  I  have  yet  a  sufficiency  to  war- 
rant the  conclusion  that  timely  amputation  seems  to  me  to 
be  the  surest  means  to  arrest  and  destroy  the  consequences 
of  tetanus,  if  the  latter  depends  upon  a  wound  situated  at  the 
extremities. 

Without,  at  present,  stopping  any  longer  at  the  theoretical 
exposition  of  the  phenomena,  occasioned  through  traumatic 

*  See  Clinique  Chinirciicalc,  Vol.  III. — Translator. 


Tetanus. — Cases.  71 

tetanus,  but  intending  to  recur  in  a  still  more  conspicuous  man- 
ner to  all  the  symptoms  to  which  it  gives  birth,  to  all  the 
modifications  which  are  caused  in  this  disease  by  climate, 
seasons,  and  by  other  circumstances,  as  well  as  in  order  to 
justify  the  principles  which  we  have  laid  down  and  the  new 
remedies  which  we  have  indicated  in  the  course  of  our  work, 
we  propose  to  relate  a  series  of  cases,  collected  during  our 
numerous  campaigns.  In  comparing  these  cases  with  the  gen- 
eral account  which  we  have  just  given  of  the  disease,  there  will 
be  occasion  also  sometimes  to  record  interesting  observations 
either  upon  the  causes,  or  the  pathological  phenomena,  circum- 
stances of  which  I  have  not  as  yet  spoken,  because  their  rela- 
tion appeared  to  me  more  properly  placed  amongst  the  particu- 
lar facts  which  caused  them  to  be  displayed. 

Cases  of  Partial  and  General  Tetanus. 

Peter  Genet,  a  sergeant  of  the  fourth  half-brigade  of  light  in- 
fantry, aged  30  years,  of  a  dry  and  bilious  temperament,  enter- 
ed the  hospital  (a  farm  of  Ibrahim  Bey,  in  Egypt)  on  the  4th  of 
October  1800,  with  every  appearance  of  opisthotonos;  his  jaws 
were  locked,  the  muscles  of  the  face  convulsively  and  perma- 
nently contracted,  the  head  thrown  back  upon  the  trunk,  the 
lower  extremities  rigid  and  extended,  the  walls  of  the  abdomen 
contracted  and  approximated  to  the  vertebral  column,  the  pulse 
small,  respiration  laborious,  deglutition  and  speech  difficult. 

The  complaint,  which  had  broken  out  twenty-four  hours 
before  entering  the  hospital,  ajDpeared  to  have  no  other  cause 
but  a  fall  upon  the  nose,  five  days  previously,  which  was  attend- 
ed by  some  slight  epistaxis  and  a  trifling  excoriation  of  the 
part.  There  was  not  the  least  sign  of  fracture,  or  of  concuss- 
ion of  the  brain. 

Blood-letting,  opiates,  cooling  drinks  and  anodynes,  tepid 
baths  and  emollient  applications  to  the  nose  were  immediately 
administered.  No  beneficial  result  having  been  produced  by 
the  repetition  of  these  remedies,  I  requested  the  health-officer 
who  had  the  particular  charge  of  the  patient,  to  apply  the  actual 
cautery  over  the  passage  of  the  facial  nerve,  and  to  the  soles  of 
the  feet;  according  to  the  aphorism  of  Hippocrates,  section  viii, 


72  Tetanus. — Cases. 

Quse  ferum  non  sanat,  ea  ignis  sanat,  &c.  I  put  on  nine  suffi- 
ciently large  and  incandescent  irons.  Their  application  instant- 
ly augn.ented  the  pains  and  the  convulsive  contractions  of  the 
muscles.  Those  of  the  larynx,  the  pharynx  and  of  the  pari- 
etes  of  the  mouth  were  violent  and  had  nearl)'-  suffocated  the 
patient;  nevertheless,  that  crisis  was  followed  by  some  rest, 
sufficient  to  inspire  us  with  the  hope  of  some  success  from  the 
employment  of  this  remedy.  But  two  or  three  hours  after- 
wards, convulsive  motions,  violent  contractions,  cold  and  clam- 
my sweats  made  their  appearance;  at  length  in  the  night  of  the 
10th  to  the  11th  December,  death  terminated  the  torments  of 
the  unfortunate  man,  the  seventh  day  after  the  attack  of  tetanus. 
Notwithstanding  the  unsuccessful  issue,  after  the  application 
of  the  actual  cauter)'-,  in  the  instance  just  read,  I  have  since 
become  convinced  that  this  remedy  is  capable  of  producing  the 
happiest  results,  especially  if  immediately  applied  to  the  wound 
which  induced  the  tetanic  affection.  We  are  going  to  relate 
several  cases,  by  briefly  stating  at  the  head  of  each  of  them  the 
pathological  phenomena  for  the  cessation  of  which  we  had 
advised  it. 

Cases  of  the  Ligature  of  a  Nerve  and  of  the  Influence  of 
the  Cold  and  Moist  Air. 

Charles  Yonck,  a  fusilier  chasseur,  after  having  undergone 
the  operation  of  amputation  of  the  right  thigh,  on  account  of  a 
most  extensive  shattering  of  the  knee  by  a  cannon  ball,  about  the 
eighth  or  the  ninth  day  was  attacked  with  tetanus.  The  irri- 
tation and  nervous  spasm  emanated,  according  to  the  statement 
of  the  patient,  from  that  point  which  corresponded  with  the 
ligature  of  the  blood  vessels.  The  suppuration  was  diminished 
and  had  become  sanious.  We  employed  for  the  dressings  the 
unguentum  epispasticum;*  we  prescribed  hot,  oleaginous  and 

•  The  unguent,  epispast.  is  a  combination,  in  the  liquid  state,  of  equal  parts, 
say  one  ounce  each,  of  the  unguent,  basilicum  and  unguent,  populeum,  with  the 
addition  of  eighteen  grains  of  powdered  canthaiides.  The  unguent,  populeum  is 
composed  of  the  young  shoots  of  the  black  poplar,  of  suet,  of  the  fresh  leaves  of 
the  black  poppy, — of  the  belladonna,  of  hyoscyamus,  and  of  solanum  nigrum. — 
Translator. 


Tetanus. — Cases.  73 

camphorated  liniments  over  the  entire  surface  of  the  body,  and 
diaphoretic  and  opiated  draughts  in  large  doses.  All  these 
remedies,  which  were  carefully  administered  for  three  days, 
scarcely  retarded  the  progress  of  the  disease.  Suspecting  that 
one  of  the  principal  cords  of  the  crural  nerve  was  included 
within  the  ligature  of  the  femoral  artery,  which  had  not  yet 
come  off,  I  cautiously  introduced  by  means  of  a  grooved  direc- 
tor the  point  of  one  of  the  blades  of  my  scissars,  betwixt  the 
artery  and  the  knot  of  the  thread,  which  I  cut  through  with 
facility.  This  simple  operation  appeared  to  compose  the  teta- 
nic symptoms  for  the  space  of  a  few  moments,  but  the  irritation 
had  extended  too  far,  and  I  am  of  opinion  that  the  principal 
exciting  cause  was  the  impression  of  a  cold  and  moist  air  to 
which  the  patient  had  been  exposed  during  a  stormy  night, 
after  having  suffered  from  the  extreme  heat  of  the  preceding 
day;  this  bleak  air,  however,  had  irritated  the  extremities  of 
the  divided  nerves. 

The  sjanptoms  steadily  went  on  increasing,  and  deglutition 
had  already  become  difficult,  when  I  decided  upon  the  applica- 
tion of  the  red  hot  iron  to  the  entire  surface  of  the  stumjD.  I 
burnt  down  upon  the  whole  extent  of  the  wound.  Several 
hours  afterwards,  although  the  operation  had  been  very  pain- 
ful, to  my  great  surprise,  a  marked  improvement  became  per- 
ceptible. The  jaws,  which  had  been  locked,  could  be  opened  at 
pleasure,  and  deglutition  was  more  easily  performed.  The  rigi- 
dity of  the  muscles  gradually  disappeared;  the  suppuration  of  the 
wound  became  re-established,  and  the  sloughs  produced  by  the 
cautery  separated  in  succession.  The  cicatrization  of  this 
wound  commenced  from  the  circumference  towards  the  centre, 
and  before  the  expiration  of  the  second  month,  Charles  Yonck 
was  completely  restored.  The  use  of  camphor,  opiates,  and 
diaphoretic  drinks  had  not  been  discontinued. 

Another,  of  the  name  of  John  Weisse,  whose  left  thigh 
had  been  amputated,  was  attacked  with  the  same  complaint 
on  the  fifth  day  after  the  operation.  We  successively  employ- 
ed all  the  above  remedies.  The  actual  cautery  was  the  last, 
of  which  the  first  application  was  sufficient  to  disperse  all  the 
symptoms  of  tetanus. 
K 


74  Tetanus — Cases. 

Jin  Instance  of  Nervous  Laceration,  and  of  the  Utility  of 

Incisions. 

Upon  the  occasion  of  a  charge  of  cavalry,  M.  Markeski,  a 
lieutenant  of  a  regiment  of  light  horse,  received,  whilst  in  Aus- 
tria, a  thrust  with  a  lance  on  the  right  side  of  the  forehead. 
The  point  of  this  weapon  had  entered  obliquely  from  below  up- 
wards and  inwards  under  the  pericranium,  so  as  to  produce  a 
deep  fissure  in  the  substance  of  the  frontal  bone.  One  of  the 
branches  of  the  frontal  nerve  had  been  grazed  (eraillé)  by  the 
cutting- edge  of  the  lance.  In  the  night  of  the  ninth  until  the 
tenth  day,  tetanus  was  ushered  in  by  convulsive  motions  in  the 
eye-lids  of  the  corresponding  eye  and  by  loss  of  sight  in  that 
organ.  There  was  also  some  slight  aberration  of  the  mind. 
Emollients  applied  to  the  seat  of  the  injury,  and  the  exhibition 
of  diaphoretic  and  opiated  draughts  produced  no  effect  what- 
ever; the  complaint  went  on  increasing,  and  there  was  no 
doubt  that,  before  the  expiration  of  twenty -four  hours,  it  would 
have  arrived  at  the  highest  stage. 

I  sounded  the  wound  and  readily  discovered  its  whole  course; 
the  passage  of  my  probe  caused  the  patient  the  most  acute 
pains.  These  motives  determined  me  to  divide,  with  a  bistoury, 
the  entire  substance  of  the  corrugator  supercilii  muscle,  and 
the  injured  nerves  and  blood-vessels  distributed  to  it,  which 
was  accomplished  by  a  single  incision  from  below  upwards. 

This  officer  experienced  immediate  relief,  and  in  less  than 
twenty -four  hours  all  the  tetanic  symptoms  were  dispersed  and 
vision  was  completely  restored.  1  had  reason  to  hope  that 
the  patient's  recovery  would  not  be  interrupted  by  any  other 
obstructions;  however,  on  the  twenty-fifth  day  after  the  wound, 
symptoms  of  effusion  and  of  inflammation  of  the  brain  and  its 
meninges  suddenly  appeared,  which  symptoms  the  pre-existing 
aberration  of  the  mind  could  not  have  failed  to  make  me 
suspect  as  uncommon  to  tetanus;  yet  it  is  proper  to  mention 
that,  till  then,  I  had  discovered  only  a  very  small  furrow  at 
the  external  table  of  the  frontal  bone,  which  had  been  produced 
by  the  point  of  the  lance.  The  application  of  a  large  blister 
to  the  base  of  the  cranium  and  the  administration  of  cooling 


Tetanus — Cases.  75 

and  antispasmodic  drinks  did  not  prevent  the  aggravation  of 
the  complaint.     The  fever  again  broke  out,  delirium  super- , 
vened,  and  the  patient  died  on  the  twenty-seventh  day  after  the 
wound. 

On  opening  the  cranium,  we  found  towards  the  extremity 
of  the  fissure,  a  lamina  of  the  internal  table  of  the  frontal  bone 
loose,  a  considerable  effusion  of  a  bloody  purulent  matter 
underneath  the  anterior  right  lobe  of  the  brain,  and  this  latter 
portion  of  the  encephalon  in  a  state  of  suppuration.  At  the 
invasion  of  the  first  symptoms  of  compression  which  had  suc- 
ceeded those  of  tetanus,  I  did  intend  to  apply  the  trephine  to 
this  fissure,  but  I  was  dissuaded  from  it  by  several  of  my  col- 
leagues, who,  from  the  smallness  of  the  fracture,  couid  not 
believe  in  the  existence  of  the  effusion. 

Cases  of  Nervous  Compression  and  Turgescence  occasio7ied 
by  the  adhesions  of  the  Nerves  to  the  Cicatrix  of  the 
Wound. 

In  Francis  Demaré,  a  grenadier,  a  bullet  in  the  strength  of 
its  career,  carried  off  the  skin,  a  portion  of  the  spine  of  the 
right  scapula,  and  parts  of  the  trapezius,  supra  and  infra  spi- 
natus  muscles.  The  division  of  the  strangulated  aponeurotic 
adhesions,  and  the  excision  of  the  disorganized  fleshy  masses, 
was  performed  upon  the  field  of  battle.  The  extraction  of 
several  bony  fragments  was  likewise  accomplished,  and  the 
wound  was  covered  up  with  fine  perforated  linen,  with  charpie 
and  a  suitable  dressing. 

The  first  stages  of  suppuration  had  passed  over  without  the 
slightest  paroxysm,  and  the  wound  began  to  cicatrize  already 
from  the  circumference,  when  suddenly  tetanus  broke  out,  and 
with  the  rapidity  of  an  electric  spark,  travelled  over  the  whole 
nervous  system,  so  that  in  a  very  few  hours  opisthotonos 
was  completely  established.  I  immediately  gave  him  dia- 
phoretic drinks,  and  ordered  him  to  take  opiates  in  large 
doses.  Camphorated  and  narcotic  oleaginous  lotions  were 
applied  over  the  whole  surface  of  the  body.  The  dress- 
ings were  mild  and  far  apart;  in  short,  every  care  and  every 
remedy  were  lavished  upon  him.    The  purulent  secretion  being 


76 


Tetanusx — Cases. 


suspended,  the  cicatrix  made  rapid  progress,  and  in  forty-eight 
hours  it  covered  half  the  wound.  The  patient  now  began  to  feel 
a  painful  and  troublesome  pinching  in  all  the  cicatrized  places; 
he  experienced,  so  he  told  us,  the  same  sensation  as  if  the  edges 
of  the  wound  had  been  seized  with  pincers;  and  the  least  touch 
of  this  very  thin  cicatrix,  particularly  the  contact  with  metals, 
such  as  iron,  steel,  &c.,  made  him  utter  violent  screams.  All 
the  symptoms  of  tetanus  became  sensibly  aggravated  ;  the  upper 
extremities  had  acquired  an  extreme  rigidity  and  were  drawn 
backward;  the  cervical  vertebrae  were  completely  turned  out, 
and  deglutition  was  out  of  the  question.  In  vain  was  the  ex- 
traction of  two  incisor  teeth  performed,  for  the  purpose  of 
admitting  through  it  the  sucking  bottle;  he  could  no  longer 
pass  a  drop  of  fluid  into  the  œsophagus,  and  the  approach  of 
limpid  water  excited  convulsive  motions;  the  patient  enter- 
tained the  utmost  aversion  for  it.  During  these  critical 
moments  the  froth  from  the  saliva  accumulated,  and  all  other 
symptoms  arrived  at  the  highest  pitch.  At  length  this  ill- 
fated  individual,  who  had  not  as  yet  shown  the  slightest  sign 
of  mental  aberration,  drew  nearer  the  termination  of  his  ex- 
istence, and  would  probably  have  expired  within  twenty- 
four  hours,  if  I  had  not  taken  the  resolution  to  employ  the 
actual  cautery.  I  therefore  caused  four  large  and  thick  cau- 
terizing irons  to  be  heated  red  hot,  even  to  incandescence, 
which  I  without  intermission  applied  one  after  the  other  to  the 
whole  extent  of  the  wound,  in  such  a  manner  that  they  bore 
with  most  force  upon  those  points  of  the  cicatrix,  where  I  sus- 
pected several  branches  of  the  spinal  accessory  of  Willis  to  be 
pinched  and  tumefied.  This  operation  was  exceedingly  painful; 
nevertheless  I  had  the  courage  to  continue  the  application  till 
every  spot  of  the  wound  was  deeply  and  completely  burnt.  I 
had  scarcely  accomplished  it,  when  an  almost  general  relaxa- 
tion took  place,  which  was  preceded  by  a  copious  perspiration. 
The  patient  raised  himself  of  his  own  accord,  and  asked  for 
something  to  drink.  The  jaws  separated  spontaneously;  I  gave 
him  a  glass  of  the  nitrated  milk  of  sweet  almonds,  to  which  I 
had  added  sixty  drops  of  laudanum,  and  a  few  drops  of  Hofif- 
man's  anodyne  liquor.     I  directed  the  camphorated  narcotic 


Tetanus. — Cases.  77 

liniments  to  be  repeated,  and  the  body  to  be  wrapped  up  in 
very  warm  flannels.  The  sweat  became  abundant;  and  a  com- 
plete composure,  accompanied  by  a  profound  sleep  of  several 
hours,  was  obtained.  The  next  morning  I  found  the  patient 
free  from  all  tetanic  symptoms;  there  remained  hardly  any 
stiffness  in  the  jaws  and  the  spine.  The  dressings  were  sim- 
ple and  gently  applied.  The  sloughs  separated  about  the  ninth 
or  the  tenth  day;  the  cicatrization  recommenced  soon  after, 
unattended  by  pain.  After  his  entire  recovery  nothing  re- 
mained but  some  constraint  in  the  motions  of  the  shoulder  and 
of  the  arm  of  the  same  side.  This  is  one  of  the  most  remarka- 
ble cures  in  military  surgery. 

James  Lucas,  a  fusilier  grenadier,  had  the  calf  of  his  left  leg 
shot  off  by  a  bullet  which  struck  him  whilst  in  the  strength  of 
its  career;  he  was  dressed  on  the  field  of  battle  under  the  same 
precautions  as  the  preceding  individual.  The  wound  had  al- 
ready begun  to  cicatrize,  when  it  was  overtaken  by  the  super- 
vention of  tetanus.  We  had  equally  recourse  in  this  case  to 
all  the  remedies  of  which  we  have  spoken,  insisting  especially 
upon  the  exhibition  of  opium  in  large  doses.  Opisthotonos 
became,  nevertheless,  developed,  and  advanced  to  the  third 
stage,  though  in  a  slow  and  gradual  manner.  A  few  days 
afterwards  the  jaws  closed  and  deglutition  became  more  and 
more  difficult.  Being  already  convinced  of  the  inefficacy  of 
the  above  cited  mode  of  treatment,  I  hesitated  no  longer  to 
apply  to  him  the  actual  cautery.  I  obtained  a  result  almost 
as  happy  as  it  was  prompt;  there  rem.ained  only  a  slight  con- 
striction in  the  jaw,  and  some  stiffness  in  the  spine  and  in  the 
affected  foot  and  leg.  After  the  sloughs  from  the  first  appli- 
cation of  the  cautery  had  fallen  off,  I  repeated  it  a  second  time, 
whereby  all  the  tetanic  symptoms  were  completely  subdued. 
All  that  yet  remained  to  be  done  was  the  cicatrization  of  the 
wound,  and  this  was  in  a  fair  condition;  but,  in  consequence 
of  an  excessive  debauch,  the  patient  was  attacked  with  a  slow 
fever  and  gangrene  of  the  leg:  from  that  period  the  success  of 
my  measures  was  defeated,  and  this  soldier  soon  afterwards 
perished  a  victim  to  his  own  imprudence.  It  is  evident  that 
the  tetanic  affection  was  completely  cured. 

Another  soldier  had  the  index  finger  of  his  right  hand  ex- 


78  Tetanus. — Cases. 

tirpated  at  the  metacarpo-phalangial  articulation  by  a  shot  re- 
ceived by  this  finger  in  the  battle  of  Esslingen.  A  vexatious 
hemorrhage  from  one  of  the  digital  arteries  compelled  us  to 
apply  a  ligature  to  the  bleeding  vessel,  in  which  the  nervous 
branch  accompanying  it  was  included.  Several  days  elapsed 
without  any  symptom,  and  the  cicatrix  was  nearly  formed, 
when  tetanus  manifested  itself.  I  hastened  to  cut  off  the  liga- 
ture which  had  not  yet  become  loose.  This  operation  made 
no  change  in  the  condition  of  the  patient.  The  disease  even 
continued  to  increase,  and  to  threaten  his  existence.  Under 
these  circumstances  I  applied  the  actual  cautery  to  the  short 
stump  as  far  down  as  possible,  which,  as  if  by  enchantment, 
caused  the  disappearance  of  all  the  tetanic  symptoms. 

Cases  of  Tetanus  ty^eated principally  by  internal  remedies. 

A  Mameluke  of  Mourad  Bey,  of  the  name  of  Mustapha,  aged 
twenty-seven  years,  of  a  dry  and  bilious  constitution,  received 
a  gun-shot  wound  on  the  19th  April  1800,  which  shattered  the 
first  phalanges  of  the  fingers  of  his  right  hand,  the  correspond- 
ing metacarpal  bones,  and  carried  off  the  thumb  at  its  articula- 
tion with  the  trapezium:  several  tendons  or  ligaments  were 
torn  off  or  lacerated.  Every  attention  which  had  been  shown 
him,  being  administered  without  knowledge,  had  been  of  more 
harm  than  use,  so  that  Mourad  Bey,  on  ISth  May  following, 
sent  him  to  the  French  surgeons,  and  requested  General  Don- 
zelot  to  recommend  him  to  their  especial  care. 

All  the  symptoms  of  tetanus  had  been  established  for  three 
days;  the  suppuration  of  the  wound  was  serous  and  scanty; 
its  margins  were  red  and  tumefied;  the  muscles  of  the  arm 
already  contracted  and  in  a  state  of  convulsion;  the  jaws  locked; 
deglutition  was  painful;  the  patient  was  constipated  and  very 
restless. 

The  first  care  of  M.  Cellières,  surgeon  of  the  second  class 
to  the  hospital  of  Syout,  was  to  enlarge  the  wound  and  to  ex- 
tract cautiously  the  loose  fragments;  he  next  dressed  it  with 
emollients,  and  made  the  patient  take  six  grains  of  opium  com- 
bined with  four  of  camphor.  A  few  hours  after svards  he  be- 
came somewhat  composed,  and  in  the  course  of  the  succeeding 
night  was  less  excited.     This  improvement  induced  the  sur- 


Tetanus.  —  Cases.  79 

geon  to  continue  with  the  same  remedies,  the  dose  of  which 
he  merely  increased.  The  symptoms  sensibly  abated  until  the 
24th  May,  when  the  patient  was  taken  away  from  Syout  to 
Minyet;  but  the  burning  heat  of  the  day,  the  fatigue  of  the 
journey  and  the  coolness  of  the  night,  during  which  he  exposed 
himself  by  lying  on  the  terrace  of  the  hospital,  recalled  the 
tetanic  affection.  The  same  remedies  were  continued,  but  did 
not  prevent  the  complaint  from  progressing  with  its  usual  ra- 
pidity. Baths  of  tepid  water  were  tried;  the  second  of  which 
produced  a  general  relaxation,  which  enabled  the  patient  to 
swallow  the  one  half  of  a  draught  composed  of  eight  grains  of 
camphor,  eight  grains  of  musk,  and  twenty  grains  of  opium 
dissolved  in  a  glass  of  emulsion;  the  other  half  was  taken  in 
the  course  of  the  day:  a  few  moments  after  which  the  pains 
subsided  and  the  jaws  relaxed,  and  through  the  night  his  slum- 
bers were  sufficiently  quiet.  The  next  morning  a  great  im- 
provement became  manifest;  the  suppuration  of  the  wound  had 
become  re-established;  the  organs  gradually  resumed  their 
functions,  and  a  few  days  more  sufficed  to  put  the  Mameluke  in 
a  fair  way  of  recovery.  On  the  29th  June  he  was,  at  length,  in 
pretty  good  condition,  and  returned  to  the  prince  Mourad  Bey. 
General  Lannes  received,  in  the  battle  of  Aboukir,  a  shot 
which  traversed  his  leg  at  its  lower  extremity  in  the  space 
between  the  two  bones.  He  was  immediately  attended  to 
under  the  tent,  and  subsequently  transported  to  Alexan- 
dria, when  unpleasant  symptoms  began  to  appear.  At  the 
moment  he  sent  for  me,  his  leg  was  tumefied  and  the  wounds 
dry  and  painful;  he  had  subsultus  tendinum,  violent  twitches 
throughout  the  whole  limb,  and  the  foot  was  benumbed; 
his  voice  was  hoarse,,^the  jaws  pretty  nearly  closed,  the  eyes 
haggard,  and  the  fever  was  raging.  1  dressed  him  with 
emollients  and  prescribed  for  him  cooling  drinks,  absolute 
composure  and  diet.  On  my  second  visit,  three  hours  after- 
wards, all  the  symptoms  were  still  more  aggravated;  I  ordered 
him  instantly  to  be  bled  from  the  arm  and  put  him  upon  the 
use  of  emulsions,  to  which  I  added  the  purified  nitrate  of 
potash,  Hoffmann's  anodyne,  the  syrup  of  poppies,  and  orange 
flower  water,  in  proper  doses,  a  glass  full  to  be  taken  every 


80  Tetanus. — Cases. 

quarter  of  an  hour;  the  topical  emollients  were  continued. 
The  night  was  passed  in  pain;  the  next  day  the  patient  was 
in  the  same  condition  and  the  leg  greatly  inflamed;  he  swal- 
lowed with  difficulty,  and  the  jaws  were  continually  locked. 
I  directed  another  venesection,  whilst  the  same  remedies 
were  continued,  with  an  increase  of  the  dose  of  the  -antispas- 
modics. The  following  night  was  tranquil,  the  fever  diminish- 
ed, and  all  other  symptoms  abated  and  continued  to  decline: 
a  sanguineous  discharge  unloaded  the  wounds  and  the  leg,  the 
spasm  ceased  entirely,  and  the  suppuration  became  healthy 
and  abundant;  the  excretions  resumed  their  natural  course, 
sleep  was  restored,  and  shortly  afterwards  he  was  in  a  fit  con- 
dition to  return  to  France  with  the  general  in  chief,  Bona- 
parte. 

M.  Croisier,  aid-de-camp  to  the  general  in  chief,  perished 
with  tetanus  in  the  deserts  of  Catyeh  on  our  return  from  Syria, 
in  consequence  of  a  similar  wound. 

M.  Esteve,  director  general  and  comptroller  of  the  public 
revenue  of  Egypt,  was  attacked  with  a  slight  inflammatory 
quinsey,  brought  on  by  a  portion  of  fish  bone  which  had  be- 
come lodged  in  one  of  the  sinuses  of  the  pharynx,  where,  from 
its  smallness,  it  had  escaped  all  my  researches  after  it. 

On  the  thirteenth  day  after  this  occurrence,  and  the  third 
after  inflammation  had  been  established,  strong  symptoms  of 
tetanus  became  developed.  From  that  moment  I  put  the  pa- 
tient at  once  upon  the  use  of  a  sweetened  emulsion,  with  which 
I  combined,  in  sufficiently  strong  but  graduated  doses,  the  ex- 
tract of  opium,  castoreum,  camphor,  the  purified  nitrate  of 
potash  and  Hoffmann's  anodyne,  of  which  he  took  a  glass 
every  quarter  of  an  hour.  The  weak  state  of  his  pulse  did 
not  permit  me  to  make  use  of  blood-letting.  I  applied  dis- 
cutient  cataplasms  to  the  anterior  surface  of  the  neck;  I  direct- 
ed pediluvia,  emollient  clysters,  the  inhalation  of  the  steam  of 
a  strong  decoction  of  hyoscyamus,  poppy,  and  althaea  root, 
dry  frictions  over  the  entire  surface  of  the  body,  and  finally 
I  caused  every  thing  to  be  removed  which  could  trouble  his 
repose. 

Step  by  step  I  followed  up  all  the  phenomena  of  the  disorder. 


'^Tetanus. —  Cases.  ,  81 

He  was  much  excited  during  the  night;  the  pains  were  violent; 
deglutition  ceased;  the  saliva  ran  out  of  the  mouth;  the  jav/s 
Avere  firmly  closed.  The  patient  underwent  a  painful  and  per- 
petual agitation;  now  and  then  he  fell  into  a  doze  which  was 
interrupted  by  slight  fits  of  phrcnzy;  in  short  every  thing 
announced  imminent  danger.  However,  towards  four  o'clock 
in  the  morning,  a  gentle  and  copious  perspiration  on  the  chest 
and  abdomen  succeeded  that  violent  crisis:  the  patient  be- 
came composed,  and  was  enabled  to  swallow  a  glass  of  the 
emulsion  above  mentioned.  The  second  glass  increased  the  per- 
spiration and  relaxation  of  the  parts,  which  induced  me  to  draw 
a  favourable  inference  from  its  eflfects;  for,  when  the  perspiration 
is  symptomatic,  it  commences  by  the  head  and  extremities,  but, 
when  it  is  critical,  it  breaks  out  on  the  breast  and  abdomen. 
The  next  day  the  jaws  were  completely  relaxed,  deglutition  was 
easy,  and  the  muscular  contraction  considerably  lessened.  I 
substituted  volatile  liniments  for  the  discutient  cataplasms,  and 
a  bitter  and  purgative  ptisan,  instead  of  the  emulsion,  with  a 
view  to  unload  the  primae  vise  and  to  establish  the  healthy  action 
of  the  stomach.  A  few  days  after,  M.  Esteve  was  perfectly 
cured.  The  fish-bone  seemed  to  have  been  removed  by  a  mod- 
erate suppuration  which  had  been  set  up  in  the  pharynx. 

Oleaginous  frictions,  recommended  by  some  writers,  have 
been  employed  in  Egypt,  but  without  operating  the  least  change 
in  the  nature  of  the  disease. 

Mercurial  frictions  have  appeared  to  me  only  to  aggravate 
the  symptoms  in  those  to  whom  they  were  applied.  The 
employment  of  this  remedy,  even  when  used  in  venereal  dis- 
eases, requires,  in  Egypt,  the  utmost  precaution  ;  for  this  rem- 
edy, when  administered  after  the  European  fashion,  has  pro- 
duced there  disastrous  consequences,  such  as  insanity,  hepatic 
disorders,  &c. 

Cataplasms  made  of  the  leaves  of  tobacco  for  the  wounds  of 
those  persons  who  have  been  attacked  with  tetanus,  have  not 
produced  any  favourable  result  whatever.     And  the  alkalies 
have  been  employed  equally  without  success. 
L 


83 


Tetanus. — Cases. 


Cases  of  Tetanus  in  which  some  peculiar  phenomena  had 
appeared. 

A  soldier  of  the  75th  regiment  of  the  line,  having  received, 
during  the  Austrian  campaign,  a  gun-shot  wound  of  the  right 
thigh,  was  attacked  with  tetanus.  Cold  haths,  recommended 
by  some  physicians,  were  employed.  The  two  first  occa- 
sioned to  the  patient  a  most  painful  feeling,  without  improving 
his  situation  in  the  slightest  degree.  At  the  sight  of  the 
third  he  felt  an  invincible  horror  for  the  water  in  the  bathing 
tub,  into  which  he  refused  to  go;  a  bed-sheet,  however,  was 
thrown  over  him,  and  without  giving  him  previous  notice, 
he  was  plunged  into  the  water.  He  had  scarcely  been  im- 
mersed in  it,  when  the  tetanic  rigidity  increased  and  he  was 
seized  with  dreadful  convulsions.  It  became  necessary  to  take 
him  instantly  out  of  the  bath  and  to  bring  him  to  bed.  A 
tumour  of  the  size  of  a  hen's  egg  appeared  suddenly  along  the 
edge  of  the  linea  alba  below  the  umbilicus.  The  life  of  this 
unhappy  man  v/as  protracted  yet  for  several  hours,  but  towards 
the  end  of  day  all  his  functions  were  precipitately  suspended, 
and  the  next  morning  he  was  found  dead.  His  intellectual 
faculties  had  remained  sound  throughout. 

I  opened  the  body  of  this  soldier  in  the  presence  of  the  two 
surgeon  majors,  M.M.  Galette  and  Trachet,  his  physicians. 
The  whole  body  was  as  stiff  as  a  board  and  completely  straight, 
which  is  a  characteristic  sign  of  general  tetanus.  The  tumour 
which  we  had  observed  near  the  linea  alba  was  still  perceptible; 
the  walls  of  the  abdomen  were  glued  upon  the  vertebral  column, 
and  the  jaws  were  firmly  locked.  After  having  made  a  crucial 
incision  through  the  integuments  of  the  abdomen,  we  laid  open, 
by  a  well  directed  dissection,  the  parts  which  constituted  the 
tumour.  It  consisted  of  a  portion  of  the  rectus  muscle  of  the 
right  side,  retracted  upon  itself  in  the  shape  of  a  ball  of  cotton, 
this  being  the  result  of  a  rupture  of  this  muscle  throughout  its 
whole  substance.  The  rent,  indeed,  might  be  perceived  under- 
neath, and  was  filled  up  with  blackish  and  coagulated  blood. 
The  rupture  of  this  muscle,  although  very  extensive,  must  have 
been  spontaneously  produced  at  the  moment  when  the  patient 
was  plunged  into  the  cold  bath.     The  abdominal  viscera  were 


Tetanus. — Cases.  83 

reduced  to  an  exceedingly  small  volume  and  had  descended 
into  the  hypochondriac  regions  and  pelvis.  We  met  with 
some  lumbricoid  worms  in  the  small  intestines,  but  not  the 
least  sign  of  inflammation.  The  ventricles  of  the  heart  were 
empty  and  its  parietes  approximated  each  other.  The  brain 
presented  nothing  particular.  In  the  dissection  of  the  wound- 
ed thigh  we  discovered  the  bullet,  adhering  to  the  linea  aspera 
of  the  OS  femoris,  near  the  great  trochanter.  The  crural  and 
sciatic  nerves  had  been  injured  by  the  entrance  and  passage  of 
the  bullet;  and  it  is  no  doubt  owing  to  this  twofold  lesion  that 
tetanus  was  occasioned. 

A  fusilier  chasseur  who  in  the  same  campaign  had  a  por- 
tion of  the  tarsus  of  the  right  foot  carried  off  by  a  three 
pound  ball,  had  been  seized  with  tetanus,  when  I  recommended 
to  him  the  propriety  of  amputating  the  leg,  which  the  very 
nature  of  the  injury  required.  But  he  declined  the  opera- 
tion, and  I  was  compelled  to  confine  myself  to  the  use  of 
opiates,  diaphoretics  and  camphorated  narcotic  liniments.  The 
progress  of  the  symptoms  became  slower,  and  the  ajSection 
assumed  a  chronic  character,  that  is  to  say  the  general  stiffness 
remained  nearly  of  the  same  degree.  The  wound  also  was 
almost  always  without  suppuration,  in  spite  of  the  application 
of  suppurative  epispastics.  The  complaint,  however,  increas- 
ed imperceptibly,  and  emprosthotonos  became  established. 
The  patient  at  the  same  time  felt  a  smart  pain  in  the  right  elbow 
of  the  same  side  of  the  wound;  in  addition  to  which  swelling, 
redness,  and  all  the  symptoms  of  local  inflammation  supervened. 
Anodyne  emollient  cataplasms  were  applied,  and  the  dose  of 
the  narcotics  increased,  because  of  the  steady  progress  of  teta- 
nus which  threatened  the  life  of  the  subject.  To  the  symp- 
toms of  inflammation  succeeded  th»se  of  suppuration.  The 
very  rapid  formation  of  an  abscess  took  place  above  the  articu- 
lation, and  the  fluctuation  becoming  evident,  I  forthwith  open- 
ed it,  and  let  out  a  large  quantity  of  greyish  purulent  matter. 
From  that  moment  this  soldier  decidedly  improved;  the  rigid- 
ity of  the  body  and  its  limbs  disappeared  'almost  immediately; 
his  jaws  relaxed  and  he  swallowed  with  ease  all  the  medicines 
which  were  ministered  to  him;  finally,  all  the  tetanic  symptoms 


84  Tetanus. — Cases. 

had  entirely  disappeared.  The  wound  of  the  foot,  as  well  as  that 
of  the  abscess,  afterwards  advanced  without  hindrance  in  the  pro- 
cess of  cicatrization,  and  I  anticipatedaspeedy  recovery  of  the 
patient,  when  he  was  seized  with  an  attack  of  complete  paralysis 
of  the  whole  affected  side,  and  somewhat  later  with  a  dysen- 
tery which  in  a  few  days  caused  his  death. 

It  is  self-evident  that  the  abscess  subsequent  to  the  injury  of 
the  foot,  which  supervened  upon  the  arm  of  the  same  side,  as 
also  the  hemiplegia  which  followed  it,  were  the  results  of  a 
purulent  metastasis,  and  that  the  issue  of  the  matter  of  the 
abscess  constituted  the  crisis  of  tetanus.  The  paralysis  alone 
remained,  and  would  no  doubt  have  been  removed  in  the 
course  of  time,  if  the  patient  had  survived  this  crisis. 

Case  of  traumatic  tetanus  excited  by  the  coolness  of  tfie 
nigtits,  and  aggravated  by  a  moral  affection. 

General  Daumartin,  whilst  descending  the  Nile  in  order  to 
repair  to  Alexandria,  received  four  slight  shots,  one  of  which 
went  to  the  right  leg,  another  to  the  left  thigh;  the  third  grazed 
his  chest,  and  the  bullet  of  the  fourth  entered  into  his  right 
arm;  the  former  affected  only  the  integuments  and  a  very  small 
portion  of  the  muscles.  The  general  obtained  no  assistance 
until  his  arrival  at  Rosetta,  which  occurred  on  the  fifth  day 
after  the  event.  M.  Guillier,  surgeon  major,  dressed  the 
wounds  according  to  the  principles  of  the  art,  put  him  upon  a 
strict  diet  and  on  the  use  of  cooling  beverages.  A  few  days 
afterwards,  the  bullet  was  extracted  by  him,  it  having  shown 
itself  near  the  articulation  of  the  elbow. 

The  wounds  were  in  good  condition,  and  without  the  anx- 
ieties to  which  the  patient  had  given  himself  up,  an  early  and 
safe  recovery  might  have  been  expected;  but  his  moral  emo- 
tions gaining  daily  more  and  more  the  ascendency,  some  ap- 
prehension of  an  attack  of  tetanus  was  entertained .  Indeed,  on 
the  eighth  day  after  the  accident,  the  suppuration  of  the  wounds 
was  considerably  diminished,  and  the  dressing  of  them,  though 
made  with  the  utmost  precaution,  was  very  painful.  The  next 
day  all  the  symptoms  of  tetanus  were  fully  displayed;  they 


Tetanus. — Cases.  85 

travelled  rapidly,  and  terminated  fatally  on  the  fifteenth  day 
after  the  infliction  of  the  wound. 

The  termination  of  the  disease,  perhaps,  might  have  been 
less  fatal,  if  upon  the  appearance  of  the  first  symptoms,  the  arm 
had  been  amputated. 

Cases  of  the  advantages  arising  from,  the  amputation  of  the 
injured  limb  i?!  tetanus. 

M.  Bonichon,  a  lieutenant  of  the  first  battalion  of  the  21st 
half  brigade  of  light  infantry,  had,  in  the  battle  of  Sedment, 
received  a  shot  in  the  left  foot.  The  direction  of  the  wound 
was  obliquely  from  behind  forwards,  passing  across  the  instep, 
of  which  several  of  the  bones  were  fi'actured;  the  extensor  bre- 
vis  muscle  of  the  toes  and  the  corresponding  articulating  liga- 
ments were  ruptured.  Nevertheless,  on  his  arrival  at  the 
hospital,  October  7th,  1798,  no  unpleasant  symptom  had  as  yet 
presented  itself;  the  first  dressings  had  been  carefully  made: 
the  wound  having  been  enlarged,  several  fragments  had  been 
extracted. 

On  the  same  evening  the  wounded  showed  some  anxiety; 
his  sleep  was  disturbed;  he  felt  acute  pains  in  the  wound  which 
continued  increasing,  until  I  visited  him  in  the  morning;  the 
edges  were  then  found  tumefied,  and  encircled  by  a  reddish 
streak;  suppuration  was  suppressed;  the  act  of  dressing  occa- 
sioned pain.  Cooling  drinks  and  anodynes,  and  the  application 
of  emollients  to  the  wound  did  not,  for  several  days,  produce 
any  effect  whatever. 

On  the  19th  of  October,  the  jaws  first  began  to  be  locked; 
on  the  20th,  all  the  symptoms  were  developed,  and  from  that 
time  assumed  a  chronic  character,  till  the  2d  November,  when 
the  disease  had  reached  the  highest  degree.  His  legs  were  stiff 
and  firmly  bent  upon  the  thighs,  and  the  latter  upon  the  pelvis; 
the  walls  of  the  abdomen  were  glued  to  the  vertebral  column; 
the  head  bent  upon  the  breast;  the  jaws  firmly  closed,  and  de- 
glutition difficult.  The  pulse  was  small  and  tremulous  (ner- 
veux) ;  the  patient  reduced  to  a  state  of  extreme  emaciation,  his 
body  being  constantly  covered  with  perspiration;  he  complain- 
ed of  continued  violent  pains  which  made  him  anxiously  look 
for  his  dissolution  as  for  a  blessing. 


86  Tetanus. — Cases. 

Having  vainly  tried  all  the  resources  which  under  such  cir- 
cumstances the  art  of  liealing  has  to  offer,  opiates  in  all  its 
forms,  combined  with  camphor  and  bark,  lotions  of  cold  water, 
solutionsof  opium  applied  to  the  wound,  emollient  cataplasms,  I 
now  conceived  the  idea  of  amputating  the  leg.  The  despondency 
of  the  unfortunate  man,  and  the  certainty  of  death  which  await- 
ed him,  determined  me,  against  the  advice  of  several  officers  of 
health,  whom  I  had  desired  to  meet  in  consultation,  promptly 
to  resort  to  this  last  remedy.  A  moment  of  calmness  which 
presented  itself  in  the  course  of  the  day,  was  taken  advantage 
of  for  the  occasion.  The  operation  was  dexterously  perform- 
ed under  my  eyes  and  in  presence  of  all  the  consulting  physi- 
cians, by  M.  Assalini,  a  surgeon  of  the  first  class.  The  patient, 
who  had  desired  it,  bore  it  courageously,  without  evincing  any 
great  pains.  A  slight  syncope,  supervening  a  few  moments 
after  the  operation,  was  the  happy  forerunner  of  the  cessation 
of  the  symptoms:  indeed,  a  general  relaxation,  which  allowed 
the  patient  to  swallow  some  fluids,  was  the  immediate  result. 
He  passed  a  quiet  night  and  had  a  few  hours'  sleep.  On  the 
next  day,  I  found  the  pulse  developed,  the  limbs  less  rigid,  the 
jaws  relaxed.  The  patient,  aided  by  some  injections,  had 
several  stools.  The  wound  began  to  suppurate  at  the  ordinary 
period,  and  all  the  symptoms  disappeared  by  degrees;  but,  still 
the  stump  continued  for  several  days  to  exhibit  violent  subsul- 
tus,  which  increased  even  by  the  slightest  external  touch, 
especially  so  during  the  act  of  dressing,  notwithstanding  the 
precautions  which  were  taken  not  to  irritate  the  parts  in  any 
manner.  I  succeeded  in  quieting  these  convulsive  motions, 
by  means  of  a  pretty  accurate  compression  which  I  directed  to 
be  made  upon  the  course  of  the  sciatic  nerve. 

He  soon  recovered  his  strength,  but  the  digestive  faculties 
for  a  long  time  remained  in  a  state  of  atony,  owing  to  the  press- 
ure which  the  muscular  walls  of  the  abdomen  had  exerted  over 
them.  In  December,  however,  this  officer  was  completely 
restored,  and  began  to  walk  on  his  wooden  leg.  Shortly  after- 
wards he,  with  other  invalids,  departed  for  France,  and  was 
admitted  into  the  Hospital  of  Invalids  at  Paris. 

The  battle  of  March  21st,  1801,  gave  me  an  opportunity  to 


Tetanus. — Cases.  S7 

cause  an  amputation  of  the  leg  to  be  performed  on  a  soldier, 
for  a  wound  similar  to  that  of  M.  Bonichon.  Although  the 
tetanic  affection  had  already  become  established,  and  that  of  an 
acute  character,  still  the  operation,  as  if  by  enchantment,  put 
a  stop  to  all  the  symptoms,  and  had  it  not  been  for  the  damp- 
ness of  the  ward  where  the  patient  was  accommodated,  and 
for  the  absolute  want  of  the  proper  means  to  defend  him  against 
the  chilliness  of  the  nights,  it  would  doubtless  have  been  attend- 
ed with  an  equally  successful  result.  He  passed  about  twelve 
hours  in  a  comfortable  and  easy  condition,  but  the  chilliness  of 
the  following  night,  more  severe  than  common,  revived  the 
symptoms,  which  resisted  all  the  indicated  remedies,  and  the 
patient  died  on  the  third  day  after  the  operation. 

Similar  results  obtained  also  in  the  case  of  a  soldier  attacked 
by  tetanus,  in  consequence  of  a  gun-shot  wound  of  the  elbow 
joint  which  he  had  received  during  the  siege  of  Saint  Jean 
d'Acre. 

At  the  time  I  saw  the  patient,  the  symptoms  had  already 
advanced;  the  amputation,  however,  of  the  arm  which  I  direct- 
ed to  be  tried,  was  followed  by  a  state  of  rest  sufficiently  great 
to  inspire  me  with  some  hope  of  success;  but,  having  been  un- 
able to  defend  him  against  the  chilliness  of  the  nights,  and 
tetanus  making  too  great  and  severe  inroads,  the  symptoms 
several  hours  afterwards  made  their  appearance  again,  and  he 
perished  likewise  on  the  third  day  after  the  operation. 

Of  the  three  cases  which  I  have  just  related,  the  operation 
for  amputation  was  attended  with  the  most  success  in  the  sub- 
ject of  the  first,  because  there  tetanus  had  assumed  already  a 
chronic  form.  This  circumstance,  indeed,  holds  out  the  great- 
est chances  of  a  successful  issue,  because  the  moments  of  inter- 
mission, between  the  fits,  may  then  be  better  selected  for  this 
operation,  whilst  in  acute  tetanus  the  career  of  the  disease  is 
altogether  more  rapid,  more  intense  and  less  intermitting. 

In  all  instances  it  is  owing,  as  we  have  said  before,  to  the 
disgorgement  of  the  vessels  and  to  the  division  of  the  nerves, 
that  an  amputation  causes  the  cessation  of  the  tetanic  symptoms; 
so  much  so,  that  although  there  was,  on  the  individual  of  the 
following  case,  no  operation  performed  embracing  the  entire 


88  Tetanus. — Cases, 

structure  of  the  limb,  I  shall  relate  it  notwithstanding,  as  a  proof 
of  the  beneficial  effects  which  amputation  is  capable  of  pro- 
curing. 

General  Destaing,  whilst  in  Egypt,  received  a  wound  from 
a  bullet  which  passed  through  the  middle,  internal,  and  poste- 
rior part  of  his  right  arm.  A  portion  of  the  biceps  and  coraco 
brachialis  muscles,  as  well  as  the  radial  and  cutaneus  internus 
nerves  were  imperfectly  cut  through.  This  wound  left  a  bridge 
of  several  lines  which  was  formed  by  the  integuments,  the 
cellular  tissue  and  some  loose  fibres. 

Although  suppuration  had  already  commenced  when  I  first 
saw  him,  he  felt  smart  pains  in  the  wound;  his  appetite  was 
impaired,  sleep  disturbed,  and  towards  evening  some  febrile 
action  manifested  itself,  I  immediately  perceived  the  necess- 
ity of  dividing  the  bridge  which  contained  some  nervous 
branches  of  the  cutaneus  internus;  but  the  patient  declining 
to  submit  to  this  simple  operation,  1  was  compelled  to  restrict 
myself  to  the  application  of  emollients  and  to  the  internal  exhi- 
bition of  such  remedies  as  were  indicated.  On  the  following 
day  the  local  pains  were  more  active;  there  were  convulsive 
motions  in  the  hand  and  fore-arm;  heat  throughout  the  whole 
body,  and  closing  of  the  jaws.  The  patient  was  extremely 
restless  and  continually  agitated.  The  rapid  strides  with  which 
the  symptoms  progressed,  determined  me  to  divide  the  bridge 
and  make  an  incision  to  the  bottom  of  the  wound,  where  I 
found  several  nervous  and  aponeurotic  filaments. 

Painful  as  this  operation  was,  the  patient  felt,  two  hours 
afterwards,  greatly  relieved,  and  so  continued.  The  suppura- 
tion was  in  good  order;  the  wound  assumed  a  clean  aspect; 
the  edges  subsided,  and  the  cicatrix  formed  in  due  season. 

Instances  of  the  Efficacy  of  the  Remedies  best  calculated 
to  ward  off  the  Tetanic  Symptoms  which  are  likely  to 
result  from  an  Amputation. 

Bonnet  Pierre  of  the  85th  half-brigade,  aged  twenty  years, 
of  bilious  and  irritable  temperament,  had  languished  ever  since 
the  campaign  in  Syria,  in  the  hospitals  of  Cairo,  on  account  of 
a  fistulous  ulcer  with  caries  of  the  bones  which  form  the  artic- 


Tetanus. — Cases.  8  9 

Illation  of  the  right  foot  with  the  leg.  The  disorganization  of 
the  parts,  and  the  state  of  marasmus  to  which  this  soldier 
was  reduced,  rendered  amputation  necessary,  the  success  of 
which  was  not  disturbed  by  an}'  untoward  event;  but,  on  the 
twenty-fourth  day  after  the  operation,  when  recovery  was 
almost  complete,  Bonnet  was  suddenly  taken  with  symp- 
toms of  tetanus,  occasioned  no  doubt  by  the  reflux  of  puru- 
lent matter,  which  still  discharged  from  the  wound.  Per- 
spiration was  likewise  suppressed  in  consequence  of  the  im- 
prudence of  the  patient  in  walking  about  at  night.  Diapho- 
retics and  opiates  were  for  several  days  given  in  large  doses, 
without  preventing  the  symptoms  from  increasing  and  ris- 
ing to  the  highest  degree.  When,  at  last,  some  anodyne 
and  antispasmodic  emulsions,  given  through  an  aperture 
which  had  been  left  after  the  loss  of  two  incisor  teeth,  had 
quieted  the  pains  in  the  stomach  of  the  patient,  a  large  blister 
was  applied  over  the  entire  surface  of  the  stump,  which  re-es- 
tablished within  twenty -four  hours  the  suppurative  process  and 
induced  a  miliary  eruption  in  the  face  and  upon  the  breast. 
From  that  moment  the  patient  grew  considerably  better;  all 
the  symptoms  of  tetanus  diminished  by  degrees;  the  functions 
were  restored,  and  on  the  fiftieth  day  after  the  operation,  this 
soldier  left  the  hospital  perfectl}^  cured. 

Peter  Grangie,  a  carabinier,  received,  at  the  siege  of  Cairo, 
a  shot  in  his  arm  which  required  amputation  on  the  spot.  For 
the  first  few  days,  nothing  interfered  with  the  operations  of 
nature;  but,  on  the  ninth,  the  patient,  after  an  exposure  to  the 
chilly  night  air,  was  attacked  with  every  symptom  of  tetanus. 
M.  Lachôme,  a  surgeon  of  the  second  class,  having  perceived 
that  the  reflux  of  the  purulent  matter  was  the  chief  cause  of  it, 
immediately  applied  the  blistering  ointment  to  the  wound, 
after  the  example  of  a  prior  success  obtained  by  myself  in  a 
similar  case.  By  this  means  the  suppuration  was  at  the  end 
of  twenty-four  hours  likewise  reproduced;  the  cutaneous 
perspiration  returned;  the  jaws  relaxed;  the  danger  disappear- 
ed, and  by  continuing  the  indicated  remedies  the  patient  finally 
recovered. 

I  wish  that  the  above  related  cases  may  have  a  tendency  to 
M 


90  Tetanus. — Cases. 

settle  the  opinions  of  army-surgeons,  on  the  treatnnent  of 
traumatic  tetanus;  that  the  unprecedented  success  of  an  opera- 
tion may  induce  them  to  resort  to  it,  and  to  abandon  a  practice 
where  at  every  step  death  stares  them  in  the  face,  for  one 
where  it  is  yet  possible  to  save  the  lives  of  many  valuable  citi- 
zens. 


DISEASES  AND  INJURIES  OF  THE  HEAD. 


Mechanical  Injuries  of  the  Cranium  and  of  the  different 
parts  of  the  Encephalon. 

We  shall  forbear  to  go  into  the  circumstantial  details  con- 
cerning these  injuries;  for  they  have  been  explained  by  every 
classical  author.  We  intend  only  to  recapitulate  briefly  the 
principal  phenomena  exhibited  by  them,  according  to  the  in- 
jury of  the  parts,  the  indications  which  they  present,  and  the 
remedies  to  be  employed  for  their  cure. 

It  may  be  observed  as  a  general  rule  that  all  wounds  of  the 
head  which  are  made  by  side-arms,  or  by  any  other  mechanical 
cause,  capable  of  producing  a  clean  and  simple  division  of  the 
integuments  of  this  part,  without  injury  to  the  bones  of  the 
cranium,  ought  to  be  closed,  but  in  such  a  way  as  not  to 
stretch  their  edges  too  much.  A  piece  of  fine  perforated  lin- 
en, spread  with  some  balsamic  substance,  or  dipped  in  warm 
sugared  or  honeyed  wine,  is  for  common  cuts  the  best  applica- 
tion to  keep  the  parts  in  their  place;  if  they  should  be  very 
extensive  or  ragged,  some  adhesive  strips  are  previously  to  be 
applied.  There  occur,  nevertheless,  some  cases,  where  a  few 
stitches  are  indicated;  such  as,  for  example,  all  wounds  with 
large  displaced  flaps,  made  at  the  expense  of  the  soft  parts  of 
the  temporal  or  occipital  regions.  The  stitches  in  such  a  case 
should  be  preceded  by  a  counter-opening,  to  be  made  at  the  base 
of  the  flap,  if  that  should  happen  to  be  at  the  inclined  side,  for 
[the  purpose  of  facilitating  the  discharge  of  the  fluids,  and  of 
[preventing  their  being  lodged  beneath  the  flap.  The  effects  of 
[the  suture  should  afterwards  be  supported  by  a  proper  retain- 
ing bandage. 


92  Injuries  of  the  Scalp  and  Cranium. 

Contused  wounds  of  the  same  parts  are  to  be  treated  nearly 
in  the  same  way;  that  is  to  say,  after  shaving  the  head  pre- 
viously, and  extracting  the  foreign  bodies,  if  any  there  are, 
they  should  be  covered  with  a  piece  of  perforated  linen,  wrung 
out  in  some  of  the  above  noticed  lotions.  It  is  not  necessary 
to  cut  down  to  them,  unless  there  be  one  or  more  culs-de-sac 
at  som.e  of  their  angles,  or  a  laceration  of  the  pericranium  with 
contusion  of  the  bones  of  the  scull.  The  operation  in  such  a 
case  is  to  be  done  by  careful  and  well  directed  incisions  from 
the  circumference  to  the  centre  of  the  solution  of  continuity. 
If  there  be  any  arteries  divided,  it  will  be  indispensably 
necessary  to  apply  a  ligature  to  them,  instead  of  employing 
mechanical  pressure,  which  incommodes  the  patient  and  gives 
rise  to  cephalalgia;  besides,  the  arteries  which  run  under  the 
hairy  scalp,  by  dint  of  the  close  adhesions  which  retain  them 
under  that  dermoid  covering,  do  not  retract  with  the  prompt- 
ness requisite  to  stop  the  further  effusion  of  blood. 

The  edges  of  the  wounds  of  the  integuments  separate  but 
little  from  one  another,  because  of  the  deficiency  of  muscles  to 
assist  in  their  retraction;  which  renders  the  enlargement  of  these 
wounds  seldom  necessary,  and  proves  the  efficaciousness  of  the 
most  simple  apparatus.  A  too  early  reunion,  however,  as  we 
have  mentioned  already,  should  be  but  rarely  resorted  to;  for 
it  is  not  only  useless,  but  may  sometimes  be  productive  of  great 
mischief,  the  reason  of  which  is  easily  assigned.  Wounds  of 
this  nature  are  pretty  commonly  attended  with  more  or  less 
violent  contusions;  and  as  the  original  occurrence  occasions  the 
laceration  of  the  capillary  vessels  of  the  hairy  scalp  and  the 
destruction  of  the  cellular  bands  which  unite  that  covering  to 
the  bones  of  the  cranium  and  to  their  external  membrane,  it  is 
therefore  an  exceedingly  rare  circumstance  when  cicatrization 
takes  place  without  some  more  or  less  copious  suppuration. 
Now,  if  a  pretty  exact  reunion  were  about  being  effected,  the 
fluids  would  not  have  a  sufficiently  convenient  place  for  dis- 
charo-ing  themselves;  and  being  thus  retained  at  every  point 
of  the  wound,  they  would  occasion  an  irritation  and  bring  on 
inflammation  and  erysipelas.  Having  afterwards  become.more 
and  more  abundant,  they  finall}''  succeed  in  making  an  internal 


Injuries  of  the  Scalp  and  Cranium.  93 

passage  for  themselves,  between  the  skin  and  the  bones,  which 
they  accomplish  with  the  more  despatch  and  facility,  as  the 
adhesive  strips  and  the  too  closely  uniting  bandages  prevent 
these  fluids  from  flowing  outwards,  and  as  there  usually  exists  a 
greater  want  of  union  betwixt  the  internal  face  of  every  part 
of  the  wound  and  the  external  surface  of  the  bones.  Now,  if 
these  fluids  shall  have  once  taken  such  a  direction,  their  infil- 
tration will  go  on  in  the  same  ratio,  if  the  external  obstruction 
which  we  have  mentioned  should  continue  to  be  in  the  way; 
therefore,  in  proportion  to  the  quantity  which  may  be  accu- 
mulated there,  and  in  proportion  to  the  deleterious  principles 
which  they  may  have  acquired,  by  their  being  confined  there 
too  long,  they  will  originate  denudations,  fistulous  passages, 
and  collections  of  matter,  or  they  will  give  rise  to  metastases; 
circumstances  which  in  themselves  would  require  not  only  the 
separation  of  the  borders  of  the  wound,  but  also  counter-open- 
ings, all  of  which  might  liave  been  avoided,  but  for  those  pre- 
mature reunions  which  we  do  not  hesitate  to  censure. 

If,  on  the  contrary,  the  solution  of  continuity  be  allowed  to 
have  a  moderate  degree  of  freedom,  keeping  it  only  in  such  a 
state  of  simple  approximation,  as  we  have  pointed  out,  the  dis- 
gorgement will  take  place  without  hinderance,  and  cicatrization 
will  subsequently  be  accomplished  almost  of  its  own  accord; 
but  the  removal  of  the  first  dressing  should  be  delayed  as  long 
as  |)0ssible,  and  never  be  attempted  before  the  seventh  or  ninth 
day. 

Wounds  of  the  head  with  simple  injury  of  the  bones  of  the 
cranium,  of  the  meninges,  and  of  the  brain  itself,  whatever 
may  be  the  species  of  arms  by  which  they  have  been  produced, 
require,  as  to  their  dressing,  the  application  of  no  other  prin- 
ciples but  those  of  which  we  have  just  now  spoken;  it  is  only 
with  reference  to  the  secondary  symptoms  to  which  they  may 
give  origin  that  a  consecutive  treatment  will  frequently  become 
necessary. 

-With  respect  to  such  wounds  as  may  be  accompanied  by 
simple  or  comminuted  fractures  of  the  bones  of  the  cranium, 
or  which  are  complicated  by  the  presence  of  foreign  bodies  or 
other  circumstances,  besides  the  important  local  indications 


94  Injuries  of  the  Scalp  and  Cranium. 

which  may  offer,  and  of  which  we  shall  speak  afterwards,  they 
are  entitled,  with  still  greater  force  of  argument,  to  a  particular 
consecutive  treatment.  This  above  all  must  be  throughout  in 
conformity  with  the  numerous  and  variable  symptoms  which  are 
likely  to  supervene,  according  to  the  spot  where  the  wound  is 
situated,  and  according  to  the  nature  of  the  organs  injured.  All 
the  resources  of  art  require,  under  such  circumstances,  to  be 
well  known,  and  executed  above  all  in  proper  season;  a 
delay  in  the  employment  of  certain  remedies,  may  do  irre- 
parable mischief,  by  their  becoming  useless,  and  often  pre- 
judicial. And  again,  there  can  never  be  too  much  attention 
bestowed  upon  the  examination  of  these  solutions  of  continuity  ^ 
never  too  much  circumspection  employed  in  the  deduction  of 
an  opinion  from  them  ;  for,  whilst  every  thing  appears  to  go  on 
well  and  prosperously,  alarming  and  truly  mortal  symptoms 
may  break  out  all  at  once,  even  after  a  considerable  lapse  of  time. 

In  a  large  majority  of  penetrating  wounds  of  the  head,  the 
welfare  of  the  patient  will  frequently  depend  upon  the  scrupu- 
lous attention  with  which  every  passing  event  is  watched,  upon 
the  sagacity  with  which  the  symptoms  which  may  present 
themselves,  and  which  are  often  obscure,  are  distinguished,  and 
upon  the  promptness  of  action  with  which  they  are  anticipated 
and  encountered.  Still,  experience  has  not  only  demonstrated 
that  superficial  lesions  of  the  brain  may  be  cured,  but  that  such 
a  happy  result  can  be  obtained  rapidly  and  without  obstacle. 

First  Observation. — At  the  insurrection  of  Madrid,  in  1808, 
one  of  our  soldiers  received  a  sword-wound  upon  the  right  side 
of  the  head  which  divided  a  large  portion  of  the  integuments, 
the  whole  parietal  protuberance,  a  part  of  the  dura  mater  and 
a  superficial  layer  of  the  cortical  substance  of  the  brain.  1 
dressed  the  wound  very  soon  after  the  occurrence.  The  bone 
being  denuded  of  the  pericranium,  was  removed,  after  which  I 
formed  out  of  the  flap  of  the  integuments  a  covering  for  the 
divided  portion  of  the  dura  mater  whose  separated  margins  I 
had  drawn  together.  We  anticipated  the  symptoms  of  inflam- 
mation by  blood-letting  from  the  jugular  vein, and  from  the  arm, 
and  by  several  cups  to  the  base  of  the  cranium  and  between  the 
shoulders.   This  wound  passed  through  all  its  stages  without  any 


Injuries  of  the  Scalp  and  Cranium. — Cases.         95 

untoward  event,  and  cicatrized  in  less  than  thirty  days.  We 
did  not  observe  the  slightest  aberration  in  the  intellectual  and 
sensitive  functions  of  this  man  whom  we  had  an  opportunity  to 
see  some  time  after  this  accident.  The  cicatrix  was  depressed, 
and  rendered  the  pulsations  of  the  brain  still  perceptible. 

Second  Observation. — Brocard  Rivière,  at  the  same  time 
and  upon  the  same  occasion,  had  received  a  sabre-wound  upon 
the  left  side  of  the  head,  extending  from  the  parietal  eminence 
to  the  fossa  innominata  of  the  ear,  which  divided  the  skin, 
the  aponeurotic  expansion  of  the  temporalis  muscle,  a  portion 
of  the  parietal  bone  as  large  as  a  five  franc  piece,  the  dura 
mater  and  a  small  slice  of  the  substance  of  the  brain.  The  flap 
had  been  replaced,  without  separating  from  it  the  fragment  of 
bone  which  still  adhered  to  the  pericranium.  The  wounded 
had  several  paroxysms;  the  symptoms,  however,  gradually 
passed  off,  and  towards  the  end  of  the  second  month  he  was 
restored  to  health,  since  which  period  we  have  had  no  further 
opportunity  to  see  him. 

During  the  campaigns  on  the  Rhine  and  in  Poland,  we  have 
seen  two  cases  analogous  to  the  above  related,  which  terminat- 
ed in  the  same  way;  still,  results  so  remarkably  successful  are 
quite  rare;  most  frequently  it  is  altogether  impossible  to 
arrest  the  progress  of  inflammation  of  the  meninges  and  the 
encephalon.  Symptoms  of  effusion  and  compression  are  some- 
times so  rapidly  developed  that  they  allow  no  time  to  watch 
them;  and  the  means  of  ascertaining  the  causes  which  produce 
them  and  the  precise  spot  which  these  causes  occupy  beneath 
the  bony  covering  of  the  cavity  of  the  cranium,  are  moreover 
so  slight  and  limited,  that  often  nothing  remains  for  us  but 
uncertainty,  inability,  and  of  course  but  little  hope  to  over- 
come them. 

The  consecutive  phenomena,  brought  on  by  the  more  impor- 
tant and  penetrating  wounds  of  the  head,  vary,  as  we  have  said, 
according  to  the  situation  of  the  solution  of  continuity,  and 
according  to  the  nature  of  the  parts  of  the  brain  which  have 
been  attacked  either  primarily,  or  secondarily.  If  the  lesions 
or  the  changes  of  the  brain  are  situated  in  the  vicinity  of  some 
one  of  the  points  of  its  anterior  or  superior  periphery,  I  have 


96  Cerebral  and  Mental  ^affections. 

observed  in  a  great  many  instances  that  the  loss  of  several 
senses  and  a  diminished  activity,  or  a  sensible  aberration  of  the 
mental  functions  mci"e  particularly  predominates.  So  true  is 
this  assertion,  that  in  all  cases  where  the  brain,  in  the  places 
alluded  to  by  us,  labours  under  compression  from  some  foreign 
body,  the  intellectual  faculties  are  immediately  restored  in  the 
same  proportion  in  which  art  may  have  it  in  her  power  to 
remove  the  pressure,  by  liberating  either  the  fluid  or  the  me- 
chanical obstruction  which  is  the  cause  of  it.  The  cerebral 
phenomena  just  spoken  of  are  in  like  manner  developed  under 
the  influence  of  other  diseases,  acting  in  an  analogous  manner. 
We  shall  again  have  occasion  to  enlarge  upon  them,  when  we 
treat  of  nostalgia,  one  of  the  affections  which  most  commonly 
originate  them. 

If,  however,  the  lesions  or  the  alterations  correspond  to  the 
base  of  the  brain  or  its  ventricles,  there  is  no  mental  aberration; 
but  various  paralytic  symptoms  may  be  observed  instead,  which 
do  not  manifest  themselves  all  at  once.  In  fact,  in  all  injuries 
of  the  head  produced  by  mechanical  causes,  in  an  oblique 
direction  from  the  base  of  the  cranium  towards  its  interior;  in 
all  metastases  from  a  mors  or  less  remote  point  towards  the  same 
part;  and  finally,  in  all  accumulations  of  fluids,  occurring  in  the 
cerebral  cavities,  the  alteration  of  the  functions  of  the  brain 
muet  present  a  different  career,  as  they  must  be  followed  by 
different  consequences.  In  all  these  cases,  the  compression 
made  upon  the  origin  of  some  one  or  all  the  nerves  of  locomo- 
tion, and  of  those  of  sensation,  and  of  the  mixed  organs,  must 
necessarily  result  in  such  symptoms,  as  the  more  or  less  decided 
loss  of  muscular  motion  and  of  the  powers  of  sensation,  as  well  as 
in  serious  derangements  of  the  functions  of  the  internal  organs. 
If  the  brain  has  been  injured  or  compressed  in  one  of  its  hem- 
ispheres, the  paralysis  invariably  manifests  itself  on  the  side 
opposite  to  the  injury  or  compression,  because,  as  every  body 
knows,  the  fibres  of  that  portion  of  the  encephalon  cross  one 
another  internally.  This  rule,  so  well  established  in  this 
respect,  admits  of  no  exception;  and  if  there  are  some  cases  to 
be  found  in  authors  which  seemingl}-  prove  the  contrary,  that 
is  to  say,  where  the  paralysis  might  have  been  observed  on  the 


Cerebral  Injuries  from  Compressioii.  97 

same  side  with  the  wound,  it  is  in  these  cases  certainly  owing 
to  a  previously  received  injury  which  must  have  been  the  cause 
of  the  hemiplegia;  but,  as  this  paralytic  symptom  may  not  have 
been  noticed  before  the  occurrence  of  another  injury  on  the 
side  which  corresponds  with  it,  so  may  this  circumstance  have 
occasioned  some  neglect  in  searching  after  the  original  causes 
which  in  reality  produced  it.     The  mistake  might  have  arisen 
also  from  the  circumstance  that  the  mechanical  or  spontane- 
ously morbific  cause  did  perhaps  simultaneously  spread  to  one 
of  the  lobes  of  the  cerebellum,  in  the  direction  of  the  crura  of 
the  medulla  oblongata,  or  of  the  posterior  portion  of  that  latter 
medullary  production,  where  the  nervous  fibres  of  these  deep- 
seated  and  posterior  constituents  of  the  encephalon  do  not  pur- 
sue the  same  method  of  reciprocally  crossing  each  other.    Thus, 
for  example,  aided  by  the  last  mentioned  reasons,  and  in  con- 
sideration of  the  origin  of  the  ninth  pair  of  nerves,   which,  as 
we  know,  arise  from  the  roots  of  the  corpora  olivaria,  can  the 
fact  be  accounted  for,  that,  in  someinstancesof  hemiplegia,  one 
half  of  the  tongue  which  corresponds  with  the  afiected  side, 
will,  in  preference,  retain  its  power  of  motion?     And,  in  like 
manner  it  happens,  because  of  the  same  mode  of  arrangement, 
that  in  compressions  and  concussions  which  concentrate  their 
force  beside  the  cerebellum,  the  utmost  difficulties  are  more 
especially  noticed  in  the  functions  of  respiration  and  deglutition. 
An  attentive  examination,  however,  of  the  cases  in  opposi- 
tion to  these  maxims,  though  reported  by  a  great  many  writers, 
will,  we  trust,  result  in  the  discovery  that  they  do  not  in  the 
least  degree  overthrow  the  truth  of  the  assertions  which  we 
have  just  now  endeavoured  to  establish,  with  respect  to  the 
essential  difierence  between  the  cause  and  seat  of  paralysis. 
Otherwise,  if  it  might  not  engage  us  too  long,  it  would  be  an  " 
extremely  easy  matter  for  us  to  prove,  by  the  very  details  of 
these  reported  cases  of  hemiplegia,  that  the  causes  which  pro- 
duced them  existed  on  the  side  of  the  brain  opposite  to  that 
which  had  become  afiected  with  hemiplegia. 

In  order  to  make  known,  at  once,  the  effects  arising  from 
an  injury  of  those  parts  of  the  brain  which  seem  to  preside 
over  the  intellectual  faculties,  we  propose  to  give  an  account  of 
N 


98  Cerebral  Injuries  from  Compression. 

several  individuals  who  had  been  wounded  in  these  verj'  same 
parts,  and  in  whom  afterwards  a  more  or  less  perceptible  aber- 
ration of  these  faculties  had  been  observed. 

First  Observation. — Joseph  Duthain,  aged  25  years,  of  a 
robust  constitution,  was  received  into  the  military  hospital  of 
Gros  Caillou,  inJuly  1821, on  account  of  a  sword  wound  which 
he  had  received  on  the  middle  part  of  the  frontal,  near  its  junc- 
tion with  the  parietal  bones.  The  weapon,  which  had  been  di- 
rected obliquely  and  with  much  force,  had  passed  through  a  por- 
tion of  the  internal  table  of  the  bone,  to  the  extent  of  about  one 
inch  in  length.  The  inflammatory  symptoms  which  had  come 
on,  were  pretty  promptly  removed  by  means  of  repeated  bleed- 
ings and  by  an  antiphlogistic  regimen.  The  only  symptom 
which  remained  in  force  for  a  great  part  of  the  time  that  the 
wound  lasted,  and  which  was  no  doubt  kept  up  by  the  existence 
of  a  slight  compression  of  the  surface  of  the  anterior  lobe,  was  a 
very  evident  incoherence  of  the  ideas  of  the  patient;  his  occa- 
sionally precise  answers  had  most  frequently  no  connexion 
whatever  with  the  questions  propounded  to  him.  This  mental 
aberration,  however,  yielded  under  the  influence  of  the  revul- 
sives which  I  directed  to  be  employed,  in  proportion  as  his 
recovery  progressed,  which  was  ultimately  accomplished  six 
weeks  after  his  admission  into  the  hospital. 

Second  Observation. — James  Letort,  a  private  of  the  second 
regiment  of  infantry  of  the  guards,  who  had  at  different  periods 
received  similar  wounds  upon  the  superior  regions  of  the  head, 
appeared  to  us  to  exhibit  a  more  decided  intellectual  derange- 
ment, when  upon  the  occasion  of  a  later  sabre  cut,  received 
also  upon  the  os  frontis  and  combined  with  injury  of  the  bone 
itself,  he  called  upon  us  to  require  our  services,  in  March  1S22. 
There  were,  as  in  the  preceding  case,  symptoms  of  inflamma- 
tion, of  cerebral  compression  and  stupor,  all  of  which  we  re- 
moved by  bleeding,  cupping,  mustard  pediluvia,  and  other 
antiphlogistic  and  revulsive  remedies. 

Although  Letort  left  the  hospital  cured  two  months  after 
his  admission,  his  looks  as  well  as  his  conversation  still  con- 
tinued to  betray  some  signs  of  a  slight  aberration.  His  com- 
rades reported  that  this  condition,  together  with  a  good  deal  of 


Effects  of  Compression  of  the  Base  of  the  Brain.     99 

caprice  in  his  notions,  must  be  constitutional  with  him,  as  for 
a  long  time  they  always  had  known  him  to  be  the  same.  It  is 
evident  that  the  numerous  wounds  which  this  soldier  had 
received  upon  the  head,  had  no  doubt  contributed  to  the  situa- 
tion in  which  he  found  himself. 

We  now  intend  to  notice  the  effects  of  compression  upon  the 
diiferent  parts  of  the  base  of  the  brain. 

First  Observation. — A  grenadier  received,  in  Austria,  a 
bullet  on  the  left  temple,  on  a  level  with  the  pinna  of  the  ear. 
The  projectile  had,  behind  that  part,  made  its  way  deeply  into 
tlie  temporal  muscle,  and  was  only  arrested  at  the  base  of  the 
mastoid  apophysis  of  the  same  side.  The  presence  of  this 
extraneous  body  was  not  perceived  at  first,  and  the  wound, 
trifling  as  it  seemed  to  be,  was  simply  dressed,  and  cicatrized 
in  about  a  fortnight.  But,  at  the  very  moment,  when  this  sol- 
dier was  about  to  leave  the  hospital,  he  was  suddenly  taken 
with  vertigo,  a  sensation  of  heaviness  and  lancinating  pains  in 
the  direction  of  the  wound. 

The  next  day,  after  a  careful  examination  of  the  whole  head, 
and  perceiving,  towards  the  base  of  the  mastoid  process,  a  small 
reddish  tumour,  pointed  and  fluctuating  at  the  centre,  I  made 
an  ample  incision  into  it,  when  I  discovered  the  bullet,  it  being 
incrusted  deeply  in  the  bony  substance.  Its  extraction  having 
been  accomplished  and  the  wound  properly  dressed,  the  patient 
was  momentarily  relieved.  The  symptoms,  however,  of  a 
cerebral  derangement  returned,  and  went  on  increasing;  a  low 
nervous  fever  (fièvre  soporeuse)  made  its  appearance,  and  the 
patient,  after  having  been  struck  with  hemiplegia  of  the  right 
side,  expired  in  a  comatose  condition. 

Upon  opening  the  cranium,  we  discovered  a  fracture  which 
passed  from  the  mastoid  process  through  the  base  of  the  petrous 
portion  and  extended  as  far  as  the  sphenoid  bone.  The  mas- 
toid cells  were  in  a  carious  condition;  the  corresponding  lobe 
of  the  brain  displayed  a  nucleus  of  suppuration,  and  some  effu- 
sion of  the  same  nature  was  found  in  the  middle  fossa  of  the 
base  of  the  cranium. 

Second  Observation. — Nicholas  Baumgartner,  23  years  of 
age,  a  soldier  of  the  8th  regiment  of  infantry  of  the  guards,  on 


100     Effects  of  Compression  of  the  Base  of  the  Brain. 

the  20th  January  1821,  whilst  in  the  act  of  fencing  with  hazel 
sticks  with  one  of  his  comrades  (both  being  somewhat  intoxi- 
cated), received  so  violent  a  thrust  in  his  left  orbit  that  he 
fell  upon  his  back  as  dead,  and  a  portion  of  the  stick,  which 
broke  at  the  moment  of  the  fall,  was  lodged  in  the  orbit,  where 
it  must  have  penetrated  deeply  and  even  entered  the  cranium. 
This  stick  of  wood,  after  having  been  pulled  out  immediately, 
was  shown  to  us,  and  was  indeed  stained  with  blood  for  a  space 
of  upwards  of  two  inches.  A  considerable  hemorrhage  from 
the  nose  and  mouth  almost  instantaneously  took  place,  after 
which  the  wounded  was  carried  to  the  hospital.  On  his  arrival 
there,  the  state  of  intoxication  in  which  he  still  was,  the  unruly 
manner  in  which  he  conducted  himself,  and  the  vomitings 
which  succeeded  each  other  incessantly,  did  not  permit  us  to 
attempt  any  thing.  All  that  under  these  circumstances  could 
be  done  were  frictions  with  hot  flannels,  applied  to  the  entire 
surface  of  the  body,  particularly  to  the  extremities,  which  were 
as  cold  as  ice. 

The  next  morning  the  eye-lids  having  formed  an  ecchymosed 
tumour  of  the  size  of  a  large  egg,  1  resolved  upon  separating 
them  for  the  purpose  of  ascertaining  the  condition  of  the  ball  of 
the  eye.  This  was  accordingly  done,  after  premising  blood- 
letting from  the  temporal  artery,  and  after  dilating  a  wound 
which  was  situated  at  the  angle  of  the  ej^e-lids.  The  eye-ball 
had  suffered  no  injury  whatever,  but  the  rontusion  it  had  sus- 
tained, was  of  so  violent  a  nature  as  to  paralyse  the  iris  and 
occasion  the  loss  of  sight.  The  corresponding  members  also 
had  lost  their  powers  of  motion.  I  endeavoured,  with  the  aid 
of  a  sound,  to  trace  the  direction  which  the  stick  had  taken, 
but  could  not  reach  itj  upon  examination,  however,  of  the  ex- 
ternal angle  of  the  eye-lids  of  the  left  side,  that  being  the  spot 
first  struck  by  it,  and  considering  that,  indeed,  it  was  the  left  side 
of  the  body  which  had  been  affected  with  hemiplegia,  I  sus- 
pected that  the  direction  of  this  stick  must  have  been  very 
oblique,  and  that  consequently  it  was  the  right  hemisphere  of 
the  brain  which  must  have  been  injured,  or  beneath  which,  at 
least;  some  effusion  must  have  taken  place.  The  autopsy  of 
the  body  of  this  individual,  as  will  be  seen  afterwards,  fully 


Effects  of  Compression  of  the  Base  of  the  Brain.     101 

proved  the  correctness  of  my  suspicion.  This  wound  and  this 
hemiplegia,  both  occurring  as  they  did  on  the  same  side,  are 
thus  well  calculated,  I  think,  to  furnish  fresh  proofs  of  the  truth 
of  the  principles  which  we  have  advanced,  respecting  the  pri- 
mary source  of  muscular  paralysis,  and  to  show,  besides,  what 
variety  of  causes  may  sometimes  be  falsely  believed  to  produce 
the  effects  of  a  change  of  structure,  especially  if  the  most  minute 
and  accurate  attention  be  not  bestowed  upon  all  the  facts  be- 
fore us. 

But,  let  us  return  to  our  narrative.  No  mental  alienation 
had  manifested  itself;  the  patient,  on  the  contrary,  complained 
in  unequivocal  terms  of  the  torments  caused  by  his  extreme 
thirst,  and  answered  quite  clearly  to  the  few  questions  which 
we  addressed  to  him,  either  by  words,  or  by  signs,  for  he  fre- 
quently found  it  difficult  to  articulate  the  sounds.  The  wound 
was  dressed  with  a  cerated  linen  rag,  and  a  little  scraped  lint; 
the  eye-lids  were  closed  again  with  a  head  band,  soaked  in  some 
discutient  lotion.  Sweetened  demulcents,  an  anodine  draught, 
clysters,  and  mustard  foot  baths  were  directed. 

On  the  22d  the  head  of  the  patient  inclined  to  the  right  side: 
but  the  hemiplegia  remained  stationary  on  the  left,  in  addition 
to  which  an  extreme  difficulty  of  swallowing  and  symptoms  oT 
paralysis  of  the  stomach  supervened,  owing  no  doubt  to  the 
compression  of  the  pneumo-gastric  nerve.  I  directed  a  scari- 
fying cupping-glass  to  be  applied  to  the  temporal  region,  and 
several  more  to  the  epigastrium  and  to  the  hypochondriac  re- 
gions; two  purgative  enemata  were  administered  in  the  course 
of  the  day,  and  in  the  evening  a  large  blister  was  put  upon  the 
whole  right  side  of  the  head. 

On  the  23d  the  situation  of  the  patient  became  hopeless;  the 
comatose  somnolency,  the  coldness  of  the  extremities,  the  pallor 
and  changed  expression  of  the  countenance  had  now  become 
too  well  marked  to  justify  any  other  but  a  gloomy  prognosis. 
Death,  indeed,  closed  the  scene  twelve  hours  afterwards.  The 
intellectual  faculties  had  never  been  impaired;  the  patient,  until 
he  expired,  having  complained  of  thirst,  of  which  we  have 
spoken  already.  We  have  reason  to  believe  that  this  symptom 
may  have  been  induced  by  the  considerable  hemorrhage  which 


102     Effects  of  Compression  of  the  Base  of  the  Brain. 

occurred  at  the  moment  when  the  stick  was  withdrawn,  as  also 
by  the  loss  of  blood  which  must  have  been  effused  into  the 
cavity  of  the  cranium. 

This  cavity  presented  upon  examination  a  thin  layer  of  blood, 
spread  over  the  posterior  surface  of  the  brain;  another  and  sim- 
ilar effusion,  only  more  considerable,  existed  within  the  basi- 
lar fossae  of  the  cranium  as  far  as  the  tentorium  of  the  cerebel- 
lum. On  searching  carefully  after  the  injuries  which  could 
have  been  occasioned  by  the  stick,  several  lacerations  of  the 
cavernous  sinuses  and  carotid  artery  were  discovered,  and  a 
piece  of  bone  belonging  to  the  right  posterior  clinoid  process 
which  had  been  fractured,  was  picked  up  near  the  sella  turcica; 
similar  fractures  were  referred  also  to  the  os  planum  and  eth- 
moid bone  of  the  left  side;  and  finally  a  small  piece  of  wood 
several  lines  long  v/as  found  sticking  in  the  very  substance  of 
the  middle  lobe  of  the  right  hemisphere  of  the  brain,  near  the 
fissure  of  Sylvius,  which  was  the  immediate  cause  of  the 
existing  paralysis. 

Third  Observation. — J. P.  Lemière,  aged  25  years,  a  pri- 
vate of  the  dragoon  guards,  was  carried  to  the  hospital  of  Gros 
Caillou,  ifl  the  night  of  March  8th,  1822.  This  soldier  had 
just  received  a  lounge  into  the  right  orbit  with  the  point 
of  a  trooper's  sword  (èpée  romaine).  The  direction  of  the 
weapon  was  from  below  upwards,  and  a  little  from  within  out- 
wards, so  that  after  having  slightly  and  obliquely  slit  the  point 
of  the  nose,  it  had  passed  through  the  integuments  of  the  inter- 
nal side  of  the  inferior  eye-lid,  opposite  to  the  nasal  process  of 
the  maxillary  bone;  had  somewhat  grazed  this  process,  and 
afterwards  pursued  its  course  between  the  floor  of  the  orbit  and 
the  ball  of  the  eye.  (On  raising  the  eye-lids,  which  being 
already  swollen,  had  closed  that  organ,  we  could  not,  indeed, 
discover  any  alteration  in  its  external  appearance;  a  protrusion 
only  of  about  half  an  inch  beyond  the  eye-ball  of  the  other  side, 
seemed  to  indicate  a  division  of  the  optic  nerve  which  might 
probably  have  occurred  at  its  extremitj»-  and  passage  through 
the  sclerotic  coat.  The  dilatation  of  the  pupil,  and  the  immo- 
bility of  the  iris  which  existed  also,  demonstrated  the  lesion 
of  the  nasal  nerve.  )     Finally  the  weapon  must  have  deeply 


Effects  of  Compression  of  the  Base  of  the  Brain.     103 

penetrated  into  the  cranium,  by  entering  no  doubt  through  the 
foramen  lacerum  superius,  and  must  have  occasioned  there  a 
considerable  effusion  by  dividing  the  blood  vessels  which  it 
encountered  on  its  route.  There  was,  indeed,  already  a  com- 
plete paralysis  of  the  left  side,  and  a  pretty  distinctly  marked 
comatose  somnolency.  The  surgeon  in  attendance  contented 
himself  with  simply  dressing  the  wound,  and  with  the  applica- 
tion of  a  mild  cataplasm  over  the  eye. 

On  the  following  day  the  hemiplegia  had  seized  upon  the 
left  muscles  of  the  face;  there  was  some  difficulty  with  respect 
to  the  mechanism  of  speaking,  but  not  the  slightest  aberration 
of  the  intellectual  faculties  could  be  perceived.  The  patient 
but  rarely  and  with  difficulty  replied  to  the  questions  directed 
to  him,  yet  when  he  did  so,  he  answered  with  the  utmost  cor- 
rectness. I  ordered  his  head  to  be  shaved,  and  bled  him  my- 
self from  the  temporal  artery,  in  consequence  of  which  he  felt 
greatly  relieved.  I  directed  the  dressing  which  had  been 
made  the  evening  before,  to  be  reapplied,  recommended  vene- 
section from  the  arm  in  the  course  of  the  day,  and  prescribed 
a  ptisan  of  barley  gruel,  sweetened  with  honey  and  two  glasses 
of  an  aromatized  and  sugared  emulsion. 

Two  days  later,  and  in  spite  of  all  the  remedies  which  I  em- 
ployed, the  symptoms  of  effusion  and  paralysis  visibly  and 
steadily  increased.  Since  the  occurrence  of  the  accident  the 
patient  had  had  no  evacuation,  and  as  several  common  injections 
given  to  him  had  produced  no  effect,  I  ordered  a  draught  with 
half  an  ounce  of  castor  oil  to  be  administered  to  him  internally, 
and  fomentations  to  be  made  to  the  abdomen  with  two  drachms 
of  resin  of  jalap,  diluted  in  four  ounces  of  olive  oil.  A  large 
blister  to  the  right  side  of  the  head  was  also  applied  on  the 
same  day.  On  the  16th  there  was  a  marked  improvement, 
with  less  drowsiness,  which  afforded  us  another  opportu- 
nity to  convince  ourselves  again  that  the  intellect  of  the 
patient  had  not  sustained  the  slightest  injury.  Copious  alvine 
evacuations,  although  involuntarily,  had  now  taken  place,  which 
intimated  to  us  that  the  sphincters  participated  in  tlîeparal3'sis; 
the  muscles  of  the  throat,  likewise,  could  no  longer  fully  per- 
form their  functions.     With  a  view  to  excite  the  action  of 


104     Effects  of  Compression  of  the  Base  of  the  Brain. 

the  pneumo-gastric  nerve,  I  directed  one  moxa  to  be  applied 
to  the  epigastrium,  and  a  fomentation  with  ammoniacum  to  be 
made  to  the  abdomen.  Frictions  over  the  whole  body  with 
camphorated  oil  of  chamomile,  were  also  resorted  to. 

The  next  day  one  grain  of  potash  was  put  to  the  base  of  the 
cranium,  between  the  mastoid  process  and  the  inferior  occipital 
protuberance.  The  patient  did  not  the  less  relapse  into  his 
insensibility  and  somnolency;  and  as  the  pulse  still  exhibited 
some  symptoms  of  irritation,  I  bled  him  from  the  foot.  During 
that  operation  and  for  some  time  afterwards,  the  motions  of 
the  patient  were  observed  to  be  more  free,  and  he  was  again 
able  very  correctly  to  reply  to  the  questions  put  to  him.  This 
second  improvement  unfortunately  was  not  of  long  duration; 
his  teeth  and  his  tongue  became  fuliginous;  the  oppression  and 
insensibility  increased  rapidly;  and  finally  the  patient  expired 
in  the  middle  of  the  night  of  the  23d,  after  uttering  some  plain- 
tive screams. 

The  day  following  his  body  was  opened.  The  wound  of 
the  nose  was  cicatrized,  and  that  of  the  eye-lids  was  almost 
completely  so.  The  scull-cap  having  been  cautiously  removed, 
an  effusion  of  blood  between  the  dura  mater  and  the  cranium 
presented  itself.  This  effusion  formed  a  pretty  thick  layer, 
and  was  nowhere  perceptible  but  at  the  injured  side  and  at  its 
posterior  part.  At  the  last  portion  only  of  the  right  hemis- 
phere, the  brain  appeared  to  us  to  be  of  greater  volume,  more 
dense  and  injected  than  in  its  normal  state.  In  raising  the 
anterior  lobe  of  the  right  hemisphere,  a  portion  of  its  cor- 
tical substance  was  found  involved  in  a  fracture  which  existed 
at  the  roof  of  the  orbit,  and  extended  as  far  as  the  base  of  the 
apophysis  of  Ingrassias.  This  fracture  ran  in  a  somewhat 
oblique  direction.  The  weapon,  however,  had  not  at  all  injur- 
ed this  anterior  lobe;  it  had  only  grazed  it  so  as  to  bear  entirely 
upon  the  middle  lobe,  which  had  been  completely  transfixed. 
Upon  examining  the  internal  surface  of  the  roof  of  the  crani- 
um, there  was,  indeed,  a  puncture  perceptible,  with  a  fissure 
about  three  lines  long  by  two  in  depth,  at  the  middle  of  the 
right  parietal  bone,  and  about  half  an  inch  from  the  sagittal 
suture.     Along  the  whole  course  of  the  weapon  through  the 


Effects  of  Compression  of  the  Base  of  the  Brain.     1 05 

parenchyma  of  the  brain,  that  substance  was  softened  and  con- 
verted into  small  friable  grains  of  the  colour  of  wine-lees, 
whilst  every  where  else  its  density  by  far  exceeded  lliat  of  its 
natural  condition;  the  ventricle  had  not  been  opened  at  all; 
its  interior  as  well  as  the  spinal  canal  contained  a  little  reddish 
serum.  The  peduncle  of  the  optic  nerve  had  not  been  so  com- 
pletely severed  as  we  had  suspected;  this  nerve  had  sustained 
only  some  injury  lengthwise,  and  then  only  in  its  orbitar  por- 
tion. It  is  to  be  observed  here,  that  the  sight  of  the  left  eye 
had  not  experienced  the  slightest  alteration. 

The  thoracic  and  abdominal  cavities  did  not  present  any  very 
remarkable  signs  of  injury.  Two  pretty  considerable  intus- 
susceptions were  discovered  in  the  intestinal  tube. 

This  exceedingly  curious  case  shows  to  what  depth  and  extent 
the  brain  can  be  injured  without  the  immediate  destruction  of 
the  vital  principle. 

Fourth  Ohservatio7i. — During  the  campaign  of  Moscow, 
Barbin,  a  young  grenadier  of  the  ex-guards,  received  from  the 
hands  of  a  Cossack  a  thrust  with  a  lance  at  the  posterior  part  of 
the  head,  towards  the  centre  of  the  lambdoidal  suture.  The  iron 
of  the  lance  had  been  so  w^ell  tempered  that  it  penetrated  deeply 
into  the  left  posterior  lobe  of  the  brain  without  producing  a  shat- 
tering of  the  bones.  The  wounded  soldier  was  left  for  dead  on 
the  ground;  but  w-as  taken  up  several  hours  afterwards  and  car- 
ried to  the  next  town,  wiiere  the  wound  was  dressed  and  passed 
through  its  different  stages,  notwithstanding  the  obstacles  which 
occurred.  A  cure  was  effected,  but  not  without  the  loss  of  the 
majority  of  his  senses,  and  he  was  troubled  withal  with  very 
great  difficulties  in  the  exercise  of  the  functions  of  several  inter- 
nal organs.  His  intellect  had  not  become  in  the  least  deran- 
ged, and  his  limbs  had  merely  exhibited  a  few  slight  signs  of 
paralysis. 

The  effects  of  the  wound  appeared  to  us  to  have  been  con- 
centrated altogether  upon  the  nerves  arising  from  the  medulla 
oblongata,  the  glosso-phary  ngeal,  par  vagum,  hypoglossal,  spinal 
and  sub-occipital  nerves.  The  voice,  having  been  at  first  hoarse 
and  faint,  gradually  became  extinct;  the  hearing,  taste,  and 
smell  grew  weaker,  and  the  external  and  internal  muscles  of 
0 


106      Effects  of  Compression  of  the  Base  of  the  Brain. 

the  larynx  having  in  part  also  become  paralysed,  the  latter 
organ  fell  about  half  an  inch  below  its  natural  position.  It 
is  evident  from  this  unnatural  falling  down  that  the  borders 
of  the  glottis  are  retracted,  and  that  the  epiglottis  is  bent  over 
that  opening,  in  consequence  of  the  disturbance  which  the 
aryteno-epiglottidei  muscles  had  undergone;  therefore,  in  order 
to  breathe  in  the  standing  position,  the  individual  is  obliged  to 
close  his  jaws  firmly  and  continually,  so  as  to  raise  the  larynx 
upwards  by  means  of  a  simultaneous  contraction  of  the  elevator 
muscles  of  both  the  pharynx  and  the  maxillae,  after  the  fashion 
of  frogs  to  inhale  the  air  necessary  for  their  respiration. 

In  the  case  of  Barbin,  the  diaphragm,  participating  in  the 
paralysis,  can  no  longer  act  upon  the  lungs.  The  frogs,  which 
are  without  that  muscular  partition,  supply  its  place,  by  closing 
their  jaws,  as  has  been  observed  by  Heroldt;*  and  it  is  probable, 
according  to  some  experiments  made  upon  this  man  before  the 
Philoniathic  Society,  that  if  his  jaws  had  been  kept  separated 
for  a  few  seconds  longer,  he  would  have  been  suflTocated,  as 
the  frogs  perish  when  they  are  made  to  undergo  similar  expe- 
riments which  are  prolonged  for  several  moments. 

The  pharynx,  œsophagus  and  stomach  had  lost  their  func- 
tions likewise,  for  deglutition  is  performed  with  difficulty,  and 
from  that  time  this  grenadier  could  not  in  the  slightest  degree 
be  excited  to  vomit.  The  abdomen  scarcely  at  all  presents  the 
alternate  and  synchronous  respiratory  heavings  which  may  be 
observed  in  every  individual;  and  when  he  is  subjected  to  the 
most  trifling  experiments,  his  face  becomes  discoloured,  his 
body  is  bedew^ed  with  perspiration,  the  cold  to  which  his  ex- 
tremities are  habitually  subject,  increases;  the  motions  of  the 
heart  are  very  slow  and  hardly  perceptible,  and  the  pulse  is 
nearly  gone.  In  the  reclining  posture,  however,  Barbin  respires 
better  and  is  much  more  ate  ase. 

When,  at  a  later  period,  I  presented  this  soldier  to  the  medi- 
cal society  of  the  school,  and  to  the  Philomathic  Society,  the 
situation  of  the  wound  displayed  a  cicatrix  of  about  one  inch 
in  depth  by  one  and  a  half  in  length,  and  the  phenomena  which 

*  Nouveau  Dictionnaire  d'Histoire  Naturelle,  tome  x,  art.   Grenouille. 


Effects  of  Diffused  Compression.  107 

I  have  described,  still  continued  to  be  the  same.  His  intellect, 
on  the  contrary,  performed  its  functions  with  remarkable  pre- 
cision, for  he  replied  in  writing  and  with  correctness  to  all  the 
questions  put  to  him. 

These  last  cases  which  have  just  been  read,  moreover,  afford 
in  my  opinion  a  pretty  evident  proof  that  the  organs  of  induc- 
tion reside,  as  Doctor  Gall  maintains,  within  the  periphery  of 
the  anterior  and  superior  half  of  the  brain.  For  as  the  con- 
siderable effusions  which,  at  the  instance  of  these  different 
wounds,  necessarily  occurred  in  the  interior  of  the  cranium, 
could  not  rise  to  the  degree  of  elevation  of  the  hemispheres 
above  alluded  to,  so  this  portion  of  the  encephalon  remained 
sound,  until  the  nerves  which  arise  at  the  base  of  the  brain, 
and  which,  on  the  contrary,  had  been  injured  and  compressed, 
promptly  lost  their  power  of  conducting  the  vital  stimulus,  and 
allowed  the  organs  to  sink  into  a  paralytic  slate. 

When  tlie  pathological  effects  bear  upon  some  one  of  the 
points  which  serve  as  demarcations  to  the  roof  and  base  of  the 
cranium,  and  when  they,  without  concentrating  themselves 
any  where  in  particular,  are  uniformly  communicated  to  the 
neighbouring  parts,  the  symptoms  which  more  especially  be- 
long to  either  the  one  or  the  other,  may  be  seen  to  arise  simul- 
taneously or  alternately,  and  to  disperse  again  of  their  own 
accord.     The  following  case  is  a  striking  proof  of  it. 

Anthony  Moignot,  aged  25  years,  a  soldier  belonging  to  the 
train  of  artillery  of  the  guards,  had,  on  May  1st,  1832,  a  violent 
fall  from  his  horse.  The  posterior  part  of  the  head  sustained 
almost  entirely  the  weight  of  the  shock.  The  blood  flowing 
profusely  from  his  nose  and  left  ear,  he  was  taken  up  in  a  state 
of  insensibility,  and  forthwith  carried  into  the  hospital.  Several 
scarified  cups  which  the  surgeon  on  duty  applied  to  the  tem- 
poral and  occipital  regions,  to  the  nucha  and  between  the  shoul- 
ders, roused  the  patient  for  a  moment  from  the  comatose  state 
into  which  he  had  sunk;  but  he  soon  relapsed,  and  thus  passed 
the  remainder  of  the  night. 

The  next  morning  1  thought  it  absolutely  necessary  to  open 
the  jugular  vein,  a  few  moments  after  which  several  of  his 
senses  returned,  although  in  an  imperfect  manner.    His  speech 


108  Varieties  of  the  Effects  of  Compression. 

was  difficult;  the  ideas  of  the  patient  were  vague  and  incoher- 
ent; and  a  satisfactory  answer  could  be  but  rarely  obtained  from 
him.  I  now  examined  the  head  attentively,  and  as  its  left 
lateral  portion  presented  a  considerably  ecchymosed  surface,  I 

made  a  deep  incision  and  put  a  cupping-glass  upon  it.  No  very 
perceptible  sign  of  a  fracture  could  be  discovered. 

May  3d. — The  patient  still  continued  to  be  very  insensible; 
when  roused  and  pressed  with  questions,  he  replied  with  dif- 
ficulty, and,  as  it  were,  in  sleep.  A  depletion  from  the  tempo- 
ral artery  gave  him  once  more  decided  relief;  but  towards  night 
these  effects  disappeared,  and  in  addition  a  slight  febrile  deli- 
rium supervened.  Diluted  and  mucilaginous  drinks  were  pre- 
scribed with  mustard  baths  for  the  feet,  and  ice  to  be  placed 
upon  the  head. 

The  next  day  there  was  a  sensible  improvement,  but  some 
difficulty  in  the  motions  of  his  arms  had  now  made  its  appear- 
ance. (Scarified  cupping-glasses  to  the  superior  region  of  the 
back,  and  a  blister  to  the  posterior  and  inferior  region  of  the 
head,  were  ap])lied  for  it.)  These  remedies  and  a  caustic  issue 
which  I  directed  to  be  made  at  the  base  of  the  cranium,  between 
the  left  mastoid  process  and  the  inferior  occipital  protuberance, 
imperceptibly  dispersed  the  above  symptoms.  The  stupor 
having  diminished,  the  patient  became  more  cheerful  and  his 
muscular  motions  more  free;  finally,  he  was  discharged  per- 
fectly cured  on  the  12th  June  following. 

Varieties  of  the  cerebral  phenomena,  after  mechanical  or 
morbid  lesions  of  the  encephalic  substance  even  more  singular 
than  those  of  which  we  have  just  now  spoken,  might  be  sub- 
mitted for  our  consideration.  These  changes,  when  they  exist 
in  the  cerebellum,  either  primarily  or  secondarily,  are  capable 
of  attacking  the  organs  or  the  functions  of  generation.  (We 
shall  return  to  this  part  of  our  theory  in  a  particular  memoir 
upon  the  injuries  and  other  affections  of  the  cerebellum.) 

A  lesion  or  a  concussion  of  certain  parts  of  the  brain,  the  pre- 
cise situation  of  which  cannot  be  well  pointed  out,  but  which, 
according  to  our  observations,  has  appeared  to  us  alone  to 
correspond  more  especially  with  some  of  the  lateral  and  a  little 
anterior  regions  of  tlie  lobes  of  this  organ,  is  mostly  attended 


Partial  Loss  of  Memory .  109 

by  the  loss  of  some  of  the  powers  of  memory;  that  is  to  say, 
individuals  who  have  become  subject  to  these  alterations,  can- 
not very  well  remember  names  and  objects  which  they  do  not 
habitually  make  use  of,  such  as  the  proper  names  of  indivi- 
duals, or  of  certain  objects,  and  particularly  very  complicated 
names. 

We  shall  not  venture  to  explain  a  peculiarity  so  astonishing; 
but  there  are  the  facts  and  it  is  impossible  to  contradict  them. 
We  shall  proceed  to  report  in  full  detail  the  instances  in  which 
these  last  mentioned  phenomena  have  more  particularly  pre- 
sented themselves  for  our  investigation. 

First  Observation. — During  the  teirible  day  of  Esslingen, 
a  young  man,  21  years  old,  was  struck  b}-  a  ball  on  tiie  left 
temple,  near  the  orbit.  This  wound  which,  when  I  saw  it, 
had  the  appearance  only  of  a  fistulous  injury,  gave  rise  to  some 
very  remarkable  phenomena.  The  left  eye  protruded  con- 
siderably outwards,  and  its  optic  functions  were  entirely  anni- 
hilated ;  the  left  side  of  the  cranium  was  sensibly  more  elevated 
and  more  developed  than  the  right,  and  presented  there,  towards 
the  temporal  region,  perceptible  to  the  eye  as  well  as  to  the 
touch,  a  space  a  finger's  breadth  wide,  which  extended  as  far 
as  the  sagittal  suture,  and  resulted  evidently  from  a  deficiency 
of  union  between  the  frontal  and  parietal  bones. 

Numerous  instances  occur  in  surgical  writings  of  the  sepa- 
ration of  the  bones  or  sutures  of  the  cranium,  which  almost 
always  terminated  fatally  before  the  ninth  day  after  the  acci- 
dent; but  I  know  of  none  so  serious  as  the  one  I  am  now  relating, 
and  the  consequences  of  which  the  patientnevertheless  survived. 
He  was,  moreover,  deprived  of  the  use  of  his  senses,  and  of 
nearly  all  the  faculties  of  the  life  of  relation;  the  internal  organs 
alone  performed  their  functions  with  some  degree  of  regularity. 

All  these  circumstances  induced  me  carefully  to  examine 
the  situation  of  the  injury.  I  probed  the  .wound  and  thought 
I  could  discover  the  ball  deeply  seated  against  the  orbit.  It 
was,  in  fact,  extracted  after  making  a  moderate  incision;  it  was 
irregularly  flattened  and  movable,  although  it  had  been  ori- 
ginally wedged  in  the  substance  of  the  bone.  The  excavation 
made  by  its  extraction  allowed  the  pulsations  of  the  brain 


110  Partial  Loss  of  Memory. 

distinctly  to  be  felt.  After  this  operation,  which  was  performed 
in  August,  the  condition  of  the  patient  appeared  to  improve; 
he  formed  a  new  language  for  himself,  after  the  manner  of 
infants  who  have  just  began  to  prattle.  He  expressed,  for 
example,  the  affirmatives  by  the  word  baba,  the  negatives  by 
that  of  lala;  and  when  he  wanted  any  thing,  he  loudly  uttered 
the  words  dada  or  lata.  At  the  commencement  of  December, 
however,  he  was  attacked  with  the  hospital  fever,  which  almost 
suddenly  carried  him  off. 

Having  been  obliged  to  return  to  France,  the  French  surgeon 
whom  I  had  entrusted  with  the  management  of  the  hospital, 
a  month  later,  had  the  extreme  politeness  (as  I  had  requested 
him  to  do  in  case  of  this  soldier's  death),  to  send  to  me  his  head 
in  a  small  cask  filled  with  a  solution  of  oxymuriale  of  mercury. 

The  dissection  of  this  head,  which  I  made  with  the  utmost 
care,  displays  the  great  resources  which  nature,  even  in  the 
most  hopeless  cases,  is  capable  of  developing.  The  dura  mater 
adhered  closely  to  the  sutures;  and  it  had  acquired  a  consider- 
able degree  of  thickness  and  consistence  precisely  over  the 
whole  extent  of  the  separation  of  which  I  have  spoken;  the 
convolutions  of  the  brain  corresponding  with  the  fracture  were 
effaced,  and  the  membranes  which  covered  this  portion  of  the 
cerebrum  were  likewise  much  thickened  and  adhered  to  one 
another.  There  was  an  aperture  at  that  part  of  the  frontal  bone 
which  is  situated  below  the  temporal  process  and  behind  the 
external  angular  apophysis;  the  margin  of  that  aperture,  which 
was  only  six  or  seven  lines  in  diameter,  was  smooth  and  round. 
Externally,  a  bony  cicatrix,  originally  the  ray  of  a  fracture, 
was  observed  to  depart  from  it,  which  extended  about  an  inch 
towards  the  frontal  protuberance  of  the  same  side.  An  attempt 
even  at  ossification  and  cicatrization  was  noticed  to  have  been 
set  up  in  the  serrated  edges  of  the  separated  parietal  and  frontal 
bones,  as  also  at  the  injured  parts  of  the  orbitar  region  of  the 
latter;  a  lamina  of  bone  which  had  been  fractured  and  depress- 
ed by  the  ball  from  the  side  of  the  orbit,  and  thus  caused  the 
compression  of  the  eye-ball  (whereby  it  had  been  displaced  and 
deprived  of  its  optic  faculties),  had  been  reunited  to  the  frontal 
bone  bv  means  of  a  membranous  substance  which  in  several 


Partial  Loss  of  Memory.  Ill 

places  was  already  ossified.  Finally,  the  cranium,  now  in  the 
collections  of  the  faculty,  presents  also  a  considerable  increase 
of  volume  in  its  whole  left  lateral  extent,  and  a  very  percepti- 
ble reduction  of  the  transverse  diameter  of  the  orbit  of  the 
affected  side. 

When  I  reflect  on  the  mechanism  of  the  extraordinary  sepa- 
ration of  the  bones  which  occurred  in  this  individual,  I  cannot 
account  for  it  in  any  other  way  than  by  supposing  that  the  ball, 
after  striking,  at  the  termination  of  its  rectilinear  course,  the 
points  of  union  of  the  frontal,  parietal  and  sphenoid  bones, 
must  have  penetrated  between  them,  by  breaking  and  depress- 
ing against  the  orbit  the  most  fragile  of  the  three  portions,  and 
by  separating  at  the  same  moment  the  two  others:  again,  in  pro- 
portion to  the  resistance  of  the  ball  which  subsequently  acted 
between  them  like  a  wedge,  must  the  effected  separation  have 
been  augmented  and  preserved  until  the  rather  remote  period, 
when  it  was  dislodged  and  finally  extracted. 

If  by  well  directed  and  cautious  exertions  the  ball  could  have 
been  extracted  in  the  beginning,  a  great  deal  of  the  organic 
eflbrts  which  were  set  up  for  its  ejection,  might  doubtless  have 
been  saved;  but,  on  the  other  hand,  would  there  not  have  been 
cause  to  apprehend  that  by  these  very  attempts  the  foreign  body 
with  the  bony  fragments  might  have  sunk  deeper  into  the  cra- 
nium and  wounded  the  brain,  or  that  the  patient  might  have 
been  exposed  to  an  alarming  hemorrhage  from  the  deep-seated 
temporal  or  meningeal  arteries  ?  1  believe,  therefore,  that  the 
wisest  plan  was  that  which  had  been  pursued.  Besides,  it  is 
very  evident  that  in  this  instance  nature  was  fully  disposed  to 
accomplish  his  recovery,  which  undoubtedly  would  have  taken 
place,  but  for  the  contagious  disease  by  which  he  had  been 
attacked. 

Second  Observation. — M.  Edward  Derampan,  an  ex-officer 
of  cavalry,  whilst  in  the  exercise  of  fencing,  on  the  2d  March 
1817,  received  a  thrust  with  a  foil  (the  point  of  which  had  been 
broken  off  on  the  breast-piece)  in  the  left  canine  region,  near 
the  ala  nasi,  in  an  oblique  direction  from  below  upwards,  and 
a  little  from  without  inwards.  The  instrument,  to  the  extent 
of  three  and  a  half  inches,  penetrated  into  the  left  nasal  fossa, 


112  Partial  Loss  of  Memory. 

passed  through  the  cribriform  plate  of  the  ethmoid  bone,  and 
doubtless  entered  from  eight  to  nine  lines  into  the  internal  and 
posterior  part  of  the  left  anterior  lobe  of  the  brain,  so  as  to 
approach  the  anterior  portion  of  the  corpus  callosum. 

A  profuse  hemorrhage  was  the  immediate  consequence  of  this 
occurrence,  and  a  proportionate  quantity  of  blood  may  proba- 
bly have  been  effused  in  the  interior  of  the  cranium,  for  M. 
Derampan  a  moment  afterwards  fainted  and  entirely  lost  the 
use  of  his  senses  which  he  only  recovered  gradually  and  imper- 
fectly. The  faculty  of  sight  was  after  a  few  days  restored  to 
the  right  eye;  the  left  was  deprived  of  it  for  upwards  of  a 
month.  The  sense  of  smelling,  which  had  been  completely 
destroyed,  after  a  certain  period  became  again  developed  in  the 
right  nostril,  and  the  patient  very  plainly  distinguished,  on  that 
side,  the  sweet-scented  alcoholic  liquids  from  those  which  were 
not  scented;  however,  the  susceptibility  for  odours  continued  to 
be  less  acute  than  that  of  the  left  side.  The  sense  of  taste  was 
equally  affected,  but  in  such  a  manner  that  the  right  half  of  the 
tongue  was  perfectly  sensible  to  sapid  impressions,  whilst  the 
left  side  was  deprived  of  that  faculty:  this  organ  inclined, 
besides,  to  the  right,  owing  to  its  resistance  to  the  hemiplegia 
with  which  the  right  side  had  been  attacked;  the  commissure  of 
the  lips  was  drawn  to  the  left.  The  sense  of  hearing,  being  at 
first  destroyed  in  the  ear  of  the  affected  side,  was  subsequently 
restored.  The  whole  right  side  which  had  been  struck  with 
paralysis,  insensibly  resumed  the  largest  share  of  its  motions. 

The  recollection  of  the  substantive  nouns  which  are  analosjous 
with  the  proper  nouns,  was  totally  lost,  whilst  the  remem- 
brance of  material  objects  and  of  all  that  is  susceptible  of 
description,  preserved  its  utmost  integrity.  Thus,  for  exam- 
ple, the  patient  perfectly  well  remembered  the  person  and 
features  of  M.  Larrey,  from  whom  he  had,  at  different  times, 
received  some  attention  for  various  complaints  and  injuries;  he 
knew  him  well,  he  saw  him  constantly  before  his  eyes,  (as  he 
used  to  express  himself);  but  he  never  could  remember  his 
name,  any  more  than  that  he  designated  him  by  that  oi M.  Chose 
(Mr  Something).  In  like  manner  had  he  forgotten  the  names 
of  his  kindred  and  friends.     He  could  not  in  the  least  recol- 


Partial  Loss  of  Memory.  113 

Ject  the  names  of  the  clivers  pieces  of  which  the  lock  of  a  mus- 
ket is  composed,  and  yet  he  could  give  an  excellent  description 
of  it.  The  mental  alienation  with  which  this  officer  had  been 
afflicted  at  first,  had  ceased;  but  every  thing  that  in  any  man- 
ner related  to  his  self-love,  or  to  his  military  success,  threw  him 
again  into  a  state  of  derangement  and  d^ep  melancholy,  while 
the  conversations  which  had  any  reference  to  his  family,  to  his 
parents  or  friends,  allowed  him  the  free  use  of  his  intellectual 
faculties. 

Third  Observation. — Lewis  Manez,  24  years  old,  a  briga- 
dier of  dragoons,  presented  himself,  towards  the  end  of  the 
year  1815,  at  the  hospital  of  Gros-Caillou,  on  account  of  a  ball 
which  had  struck  him  on  the  external  side  of  the  forehead, 
about  four  or  five  lines  from  the  left  eye-brow,  at  the  point 
which  corresponds  with  the  curved  line  of  the  temporal  region. 
This  ball,  which  had  wounded  him  at  the  battle  of  Water- 
loo, on  the  18th  of  June  of  the  same  year,  at  least  one  half 
of  its  sphere  having  penetrated  into  the  cavity  of  the  cranium, 
had  become  imbedded  in  the  substance  of  the  os  frontis, 
whilst  the  other  half  was  found  closely  united  to  the  exter- 
nal surface  of  the  bone,  but  in  such  a  manner  that  by  any  of 
the  ordinary  means  it  was  impossible  to  dislodge  the  extraneous 
body  from  its  bony  roadstead;  the  patient  having  declined  the 
application  of  the  trephine,  the  only  remaining  means  by  which 
it  would  have  been  practicable  to  make  a  passage  for  this  pro- 
jectile, of  an  extent  sufficient  for  its  extraction.  The  foreign 
body  afterwards  remained  stationary  in  the  same  place  and  re- 
lation up  to  May  28th,  1824,  at  which  period  I  had  occasion 
to  see  this  soldier  again,  then  a  sergeant  in  the  sixth  regi- 
ment of  the  royal  guards;  from  this  I  must  except,  how- 
ever, some  external  portion  of  the  ball,  which  by  the  attempts 
made  in  1815  had  been  detached.  There  remained  at  that 
time  and  place  only  a  small  fistulous  sore,  which  this  subaltern 
kept  open  by  means  of  bougies  made  of  small  pieces  of  scraped 
lint,  by  which  particular  and  daily  attention  he  had  been 
enabled  to  remain  in  service  and  to  continue  to  do  his  duty 
with  all  possible  exactness. 

The  shot  having  been  received  from  a  pretty  considerable  dis- 
P 


1 14  Partial  Loss  of  Memory. 

tance,  was  in  the  first  instance  marked  by  the  fall  of  the  wound- 
ed man,  by  a  profound  and  long  continued  syncope,  with  loss 
of  consciousness  and  the  use  of  ail  his  senses,  and  by  the  spon- 
taneous and  involuntary  discharge  of  his  urine  and  excrements. 
After  these  first  symptoms,  a  considerable  hemorrhage  took 
place  from  the  wound,  4o  which  he  owed,  no  doubt,  his  return 
to  life.  Notwithstanding  these  circumstances,  he,  with  many 
more  wounded  French  soldiers,  remained  on  the  field  of  battle 
without  relief  for  two  days  and  two  nights.  It  was  not  till 
towards  the  end  of  the  second  day  that  he  was  picked  out  and 
lifted  up  by  an  inhabitant  of  Brussels  and  carried  by  him  into 
his  own  dwelling-house,  where  this  generous  citizen  lavished 
upon  him  all  the  assistance  which  his  condition  required.  The 
surgeon  who  had  been  desired  to  take  charge  of  him,  dilated 
the  wound  and  made  some  fruitless  eSbrts  to  extract  the  foreign 
substance;  by  means  of  repeated  bleedings,  diluent  and  cooling 
drinks,  and  by  an  appropriate  regimen,  he  succeeded,  however, 
in  dispersing  the  existing  symptoms  of  compression,  which  was 
characterized  by  paralysis  of  the  extremities  of  the  right  side, by 
a  sense  of  weight  and  a  very  great  restraint  in  the  performance 
of  all  the  functions,  as  well  as  by  those  symptoms  which  indicat- 
ed already  an  inflammatory  action  in  the  whole  head.  After  this 
treatment  had  been  continued  for  several  months,  the  patient 
being  in  a  fit  condition  to  travel,  was  given  up  to  the  hospitals 
of  Paris,  where  he  afterwards  was  admitted  into  my  wards. 

The  functions  of  locomotion  were  enfeebled  and  the  whole 
periphery  of  the  wound  was  still  inflamed.  We  discovered 
very  plainly  that  the  ball  (of  the  caliber  of  the  English  musket 
balls,  which  are  by  a  tenth  part  heavier  than  ours)  was  in  reality 
imbedded  into  the  substance  of  the  os  frontis,  in  such  a  manner 
as  to  penetrate  by  one  half,  at  least,  of  its  thickness  into  the 
cavity  of  the  cranium,  as  we  have  already  noticed.  Under 
such  circumstances  we  were  convinced  that  this  portion  of  the 
lead  had  depressed  the  corresponding  part  of  the  dura  mater 
and  the  subjacent  convolution  of  the  brain  which  forms  a  pro- 
jection upon  the  lateral  and  external  part  of  the  anterior  lobe^ 
from  which  depression  the  serious  symptoms  above  mentioned 
originally  resulted,  but  which  were,  nevertheless,   gradually 


I 


Partial  Loss  of  Mc  mory .  115 

dispersed  to  such  a  degree  that  he  not  only  recovered  the  use 
of  all  his  faculties,  but  entered  once  more  upon  the  active 
military  duties  of  the  infantry  service. 

The  onlyinjuryvvhich  since  then  the  intellectual  faculties  had 
sustained,  consisted  in  the  loss  of  recollection  of  the  substan- 
tive nouns;  and  nobody  knew  better  how  to  analyse  and  appre- 
ciate the  failure  of  that  particular  faculty  than  this  young  soldier, 
because  of  his  being  the  subaltern  instructor  of  his  company. 
Thus  it  liappened  in  the  exercises  of  the  musket,  that,  after 
having  explained  all  the  manoeuvres  of  which  they  consist,  and 
after  having  given  a  description  of  the  pieces  which  enter  into 
the  lock  of  his  weapon,  he  was  obliged  to  consult  his  pocket- 
book  to  find  and  designate  the  name  of  each  of  these  pieces. 
The  same  circumstance  equally  obtained  with  respect  to  the 
soldiers  of  his  company,  whom  he  distinguished  very  well  by 
their  stature,  shape,  complexion,  or  by  the  sound  of  their  voice, 
but  whose  proper  names  he  remembered  with  difficulty,  and 
whom,  in  this  respect,  he  often  confounded  one  with  another. 
The  failure,  or  rather  the  impaired  condition  of  tlie  functions 
of  this  faculty  had  increased  from  day  to  day,  according  to  the 
statement  of  this  soldier,  while  the  other  faculties  appeared  to 
have  become  more  perfect;  yet  the  contrary  happened  at  the 
moment  of  the  accident  and  for  some  time  afterwards,   when 
all  his  functions  were  disturbed,  and  when  he  could  only  with 
difficulty  discern  the  most  simple  objects.      For  a  conside- 
rable time  he  was  at  that  period  also  deprived  of  sight  and 
hearing  on  the  wounded  side,  and  a  good  deal  restrained  in 
the  functions  of  locomotion  of  the  two  opposite  extremities. 

This  individual  having  always  opposed  the  application  of 
the  crown  of  the  trephine  to  the  most  favourable  point  of  the 
periphery  of  the  foreign  substance,  for  the  purpose,  after  having 
opened  a  free  passage,  of  dislodging  it  with  an  elevator  from 
within,  outwards,  we  did  not  deem  it  advisable  to  exert  too 
much  force  upon  the  external  surface  of  the  ball,  from  the 
fear  of  separating  it  from  the  internal  portion  which  might 
then  have  sunk  deeper  into  the  substance  of  the  brain,  and 
we  preferred  therefore  to  leave  the  process  of  expulsion  to 
the  sole  resources  of  nature,  the  more  so  as  it  was  not  con- 


116  Partial  Loss  of  Memory. 

nected  with  any  symptom  which  Imperatively  required  its 
forcible  extraction .  In  this  young  man  as  well  as  in  the  Russ- 
ian soldier  from  whose  forehead  we  extracted  a  biscayan,  as 
will  be  seen  below,  the  osseous  and  still  elastic  fibres  were  not 
ruptured  till  long  after  their  having  yielded  to  the  action  of 
the  projectile.  Growing  again  immediately  afterwards  upon 
themselves,  it  was,  in  the  case  before  us,  still  more  impossible 
to  extract  this  foreign  body,  as  it  had  divided  their  substance 
in  such  a  manner  as  firmly  to  embrace  the  portion  of  the  per- 
forated bone.  Believing,  thus,  that  it  would  be  prudent  to 
wait  until  nature  should  have  pointed  out  some  new  indication, 
we  deemed  it  expedient  to  return  this  non-commissioned  officer 
to  his  regiment. 

Ever  since  his  last  discharge  from  the  hospital,  to  November 
10th,  1827, 1  had  heard  nothing  more  of  this  soldier;  but  at  the 
latter  period  I  was  informed  by  my  colleague.  Doctor  Cornac, 
physician  to  the  hospital,  that  a  non-commissioned  officer,  then 
died  in  his  wards  of  phthisis  pulmonalis,  and  that,  if  I  wish- 
ed to  be  present  at  the  examination  of  his  body,  he  would  direct 
to  have  it  done  the  next  day. 

At  first  I  had  some  difficulty  "in  recognising  the  head  of  my 
young  sergeant;  I  had  to  inspect  and  touch  the  ball  over  and 
over  again  before  I  could  be  convinced.  His  physiognomy 
was  completely  changed,  and  his  hair  had  grown  as  white  as 
those  of  a  man  of  seventy  years  of  age.  Being  obliged  to 
respect  the  corpse  of  this  individual,  as  he  was  to  be  interred 
with  some  distinction,  I  could  not  preserve  his  head  entirely, 
so  I  merely  separat<çd  the  scull-cap  from  it,  taking  care  to  apply 
the  saw  below  the  place  of  injury.  This  section  being  accom- 
plished, we  found: 

1.  The  dura  mater  closely  adhering  to  the  entire  internal 
surface  of  the  cranium,  and  especially  so  on  the  side  of  the 
wound;  this  membrane  was  also  much  thicker  and  denser  than 
in  the  natural  state. 

2.  A  circular  excavation  of  about  one  inch  and  a  half  in 
diameter, by  four  or  five  lines  in  depth,  at  the  summit  and  some- 
what on  the  temporal  side  of  the  left  anterior  lobe  of  the  brain. 
This  excavation  was  lined  with  a  fine  reddish  membrane  which 


Partial  Loss  of  Memory.  117 

appeared  to  us  like  the  continuation  of  the  first.  Tlie  subja- 
cent portion  or  layer  of  the  brain  was  healthy  as  well  as  the 
remainder  of  the  cncephalon. 

3.  The  pedicle  of  the  ball,  at  the  base  of  which  the  vestiges 
of  the  unsuccessful  efforts  for  its  extraction  were  still  percepti- 
ble, reached  by  several  lines  beyond  the  level  of  the  periphery 
of  the  cranium,  and  the  circumference  of  the  opening  which  had 
given  it  access,  had  been  worn  slanting  from  without  inwards, 
in  consequence  of  a  process  of  worm  like  decay  (travail  de  ver- 
mouloure),  which  nature  seemed  to  have  set  on  foot  in  order 
to  facilitate  the  extraction  of  this  foreign  substance. 

4,  In  the  cavity  of  the  cranium  and  at  the  spot  correspond- 
ing with  the  wound,  we  found  a  round  eminence  of  about  one 
inch  in  breadth  and  from  four  to  five  lines  projection,  which 
had  been  formed  by  the  union  of  three  or  four  bony  fragments 
joined  together  by  a  soldering  process,  as  was  indicated  by  as 
many  lines  or  cicatrices.  It  is  very  evident  that  this  bony  emi- 
nence was  the  result  of  the  fracture  of  the  frontal  bone,  whose 
internal  table  had  been  split  in  pieces;  the  force  of  the  projec- 
tile having  been  broken  by  this  resistance,  it  remained  enclosed 
within  the  substance  of  the  bone  and  tightly  bound  by  the 
elastic  action  of  the  osseous  fibres. 

It  seems  to  me  pretty  difficult  to  explain  the  causes  of  the 
singular  phenomena  which  in  the  case  of  this  soldier  presented 
themselves  during  the  various  stages  of  the  wound.  We  shall 
attempt,  however,  to  illustrate  the  operation  of  these  causes. 

1 .  The  symptoms  which  supervened  immediately  after  the 
accident,  prove  that  a  portion  of  the  parenchymatous  substance 
of  the  brain  had  become  instantaneously  compressed  under 
the  action  of  the  bony  fragments  separated  from  the  cranium 
by  the  shock  of  the  projectile;  hence  the  prostration  of  the 
individual,  the  loss  of  consciousness,  which  was  successively 
followed  by  that  of  all  the  functions  of  the  life  of  relation,  but 
chiefly  of  the  muscular  action  of  the  two  extremities  of  the 
side  opposite  to  the  wound;  this  compression  had  been  neces- 
sarily augmented  by  the  effusion  of  blood,  which  must  have 
been  considerable,  for  although  the  hole  made  by  the  bullet 
into  the  os  frontis,  had  been  closed,  there  occurred  neverthe- 


1 1 8  Partial  Loss  of  Memory. 

less,  shortly  after  the  accident,  a  very  profuse  hemorrhage  from 
the  wound,  which  no  doubt  contributed  to  the  safety  of  the 
patient.  This  hemorrhage  could  only  have  been  caused  by 
one  of  the  meningeal  arteries  which  run  between  the  dura  mater 
and  the  cranium.  Indeed,  on  one  of  the  bony  fragments  there 
is  still  to  be  seen  a  very  large  furrow,  made  by  the  artery,  which 
at  the  moment  of  the  fracture  had  probably  been  ruptured. 
Nevertheless,  after  a  succession  of  fits,  the  symptoms  of  com- 
pression subsided;  the  effused  fluids  were  gradually  absorbed, 
the  inflammation  dispersed,  the  lacerated  or  depressed  portion 
of  the  brain  cicatrized  and  continued  to  be  borne  down  by  being 
in  permanent  contact  with  the  splinters  soldered  together, 
whichconstituted  the  eminence  of  which  wehave  beforespoken. 

We  found  the  frontal,  sagittal  and  lambdoidal  sutures  com- 
pletely obliterated,  which  perhaps  will  account  for  the  prema- 
ture old  age  of  the  individual,  as  it  was  evinced  b}''  the  white- 
ness of  his  hair  and  the  wrinkles  of  his  face.  We  shall  under 
another  head  have  occasion  again  to  speak  of  this  latter  phenom- 
enon (the  premature  ossification  of  the  sutures  of  the  cranium). 

Finally,  in  the  case  of  Manez,  nature  had  gradually,  and 
little  by  little,  accustomed  herself  to  the  presence  in  the  cran- 
ium of  this  foreign  substance,  which  after  his  recovery  was  not 
attended  by  any  other  infirmity  than  that  of  being  deprived  of 
that  portion  of  memory  which  is  destined  to  assist  us  in  recol- 
lecting names  of  persons  and  objects  not  always  before  our 
eyes.     This  kind  of  aberration  he  retained  for  ever. 

2.  The  soldering  process  of  the  broken  fragments  had  only 
taken  place  because  they  had  not  been  isolated  entirely  from 
the  adhesions  of  the  dura  mater,  and  because  the  fracture  which 
separated  them  had  not  been  so  complete  as  to  interrupt  there- 
by the  circulation  of  the  blood-vessels  of  the  bones. 

3.  In  consideration  of  this  soldering,  it  would  have  been 
imprudent,  after  the  first  weeks,  obstinately  to  insist  upon 
effecting  the  discharge  of  the  ball,  after  having  previously 
enlarged,  however,  the  opening  by  the  application  of  the  tre- 
phine, because  these  splinters  were  soldered  together  and  con- 
nected with  the  internal  circumference  of  the  aperture  of  the 
cranium. 


Partial  Loss  of  Memory  and  Sî^ht.  119 

4.  It  cannot  be  ascertained  to  what  extent  this  gun-shot 
wound  may  have  sympathetically  attacked  the  integrity  of  the 
functions  of  the  internal  organs,  the  deep-seated  injury  of  which 
caused  the  destruction  of  the  patient. 

Upon  the  whole,  this  fact,  whilst  it  justifies  the  necessity  of 
the  trephine  in  the  first  moments,  proves  nevertheless  the  great 
resources  which  nature  has  in  store  even  in  the  most  desperate 
cases. 

Fourth  Observation. — The  subject  of  this  case  is  an  indivi- 
dual in  whom,  under  the  separate  consideration  of  the  cerebral 
organs  and  of  the  characteristic  features  of  their  respective  inju- 
ries, the  most  extraordinary  anomalies  and  the  most  curious 
phenomena  have  been  exhibited. 

Lecœur,  a  fusilier  in  the  second  regiment  of  infantry  of  the 
royal  guards,  twenty-two  years  old,  of  a  robust  habit  of  body 
and  most  cheerful  disposition,  whilst  fencing  with  one  of  his 
comrades,  on  November  19th,  1820,  was  struck  violently  in 
the  right  eye  by  a  foil,  the  button  of  which  had  been  broken 
off  in  the  meshes  of  his  mask.  The  point  of  what  remained  of 
the  blade  of  this  species  of  arms  transfixed  the  superior  eye- 
lid, below  the  eye-brow,  and  on  the  internal  side  of  the  orbit, 
and  penetrated  deeply  into  the  cranium  in  an  oblique  direction 
from  right  to  left  and  from  before  backwards.  Besides  the 
right  optic  nerve  and  the  anterior  lobe  of  the  left  hemisphere 
of  the  brain  which  appeared  to  me  to  have  been  injured,  the 
weapon  must  have  ruptured  several  blood-vessels  on  its  passage, 
and  immediately  have  caused  an  effusion  in  the  vicinity  of  the 
fissure  of  Sylvius,  in  the  anterior  fossa  of  the  cranium,  and  per- 
haps even  still  farther.  The  wounded  soldier  did  not  fall  after 
this  accident,  nor  did  he  even  lose  his  senses;  but  he  was  sud- 
denly taken  with  acute  pain  in  the  head,  especially  of  the  side 
of  the  forehead  opposite  to  the  wound,  and  with  a  painful 
numbness  along  the  whole  right  side  of  the  body,  accompanied 
by  some  slight  convulsive  action  of  the  face.  This  soldier, 
who  did  not  appear  to  have  lost  his  reason  for  a  single  instant, 
caused  himself  to  be  conducted  to  the  barracks,  and  was  not 
brought  to  the  hospital  of  the  guards  until  the  next  morning. 

The  paralysis   had  already  extended  over  the  whole  right 


120  Partial  Loss  of  Memory  and  Sight. 

side  of  his  body;  the  pectoral  extremity,  in  particular,  was 
totally  deprived  of  every  kind  of  motion,  whilst  animal 
sensibility  was  kept  alive,  and  subsequently  even  increased. 
The  tip  of  the  tongue  protruded  from  the  mouth  and  inclined 
to  the  right  in  an  inverse  ratio  to  the  hemiplegia,  which  cir- 
cumstance induced  me  to  think  that  the  effusion  had  extended 
to  the  most  oblique  points  of  the  cavity  of  the  cranium.  The 
pulse,  full  and  slow,  gave  not  more  than  forty-five  or  six  pul- 
sations per  minute;  respiration  and  deglutition  were  diflScult, 
and  the  patient  could  hardly  articulate.  My  first  care  was 
to  dilate  the  small  wound  of  the  eye-lid,  it  being  then  sur- 
rounded by  ecchymosis  and  swelling,  which  had  spread 
over  the  whole  orbitar  region.  A  probe  being  next  cautiously 
introduced  to  the  bottom  of  the  wound,  I  discovered  a  per- 
foration which  seemed  to  me  to  go  towards  the  ethmoidal 
fossa;  but  in  conformity  with  my  rules  I  dared  not  venture  to 
penetrate  through  this  aperture;  it  was  sufficient  for  me  to 
know  that  it  communicated  with  the  cranium  in  order  to  form 
my  prognosis  and  direct  my  mode  of  treatment  accordingly. 

After  this  small  operation  I  bled  him  profusely  from  the 
right  temporal  artery,  and  ordered  several  scarifying  cups  to  be 
applied  to  the  nape  of  the  neck,  between  the  shoulders  and  over 
the  hypochondria;  the  feet  and  legs  were  covered  with  cata- 
plasms of  mustard  flour,  besprinkled  with  strong  camphorated 
vinegar;  and  a  bladder  filled  with  ice  was  constantly  kept  on 
the  head.  The  patient  was  put  upon  the  use  of  cooling  and 
mucilaginous  drinks;  besides  which  several  purgative  enemata 
were  administered.  In  the  evening  he  was  bled  from  the  arm. 
The  following  night  he  was  much  disturbed;  the  patient  com- 
plaining continually  of  acute  and  steady  pains  in  the  head, 
chiefly  on  the  left  side  of  the  forehead;  the  wound  caused  him 
no  uneasiness  whatever.  Upon  the  least  motion,  he  was  seized 
with  vertigo  and  disposition  to  faint.  In  addition  to  these 
symptoms,  obstinate  constipation  and  retention  of  urine  super- 
vened which  compelled  me  to  have  recourse  to  the  gum-elastic 
catheter. 

November  23(1. — The  cephalalgia  and  symptoms  of  com- 
pression of  the  brain  having  increased,  I  depleted  him  largely 


Partial  Loss  of  Memory  and  Sight.  121 

from  the  jugular  vein;   cups  to  the  nape  of  the  neck  and  be- 
tween the  shoulders  were  repeated,    and   the  application  of 
ice  to  the  head  and  of  mustard  cataplasms  to  the  legs  was  con- 
tinued.    I  persevered  also  with  the  mucilaginous  diluents,  and 
prescribed,  besides,  an  antispasmodic  draught,  with  the  addi- 
tion of  a  pretty  strong  dose  of  acetate  of  ammonia,  so  highly 
spoken  of  latterly  in  cerebral  affections.     The  retention  of 
urine  ceased  and  copious  alvine  evacuations  were  obtained. 
Two  days  later  I  directed  the  application  of  cups  to  be  renew- 
ed once  more,  and  the  superior  and  left  lateral  surface  of  the 
head  to  be  covered  with  a  blister.     The  pains,  drowsiness  and 
vertigo  dispersed.     At  length,  by  means  of  the  revulsives, 
which  I  continued  to  employ  until  the  nineteenth  day,  all  the 
functions  were  imperceptibly  restored.     The  hemiplegia  alone 
was  obstinate;  the  intellectual  faculties  had  never  been  impair- 
ed.    For,  although  labouring  under  the  impaired  mechanism 
of  speech,   the  patient  replied,   however,   with  considerable 
precision,  to  the   questions  put  to  him,  and  frequently  an- 
swered for  the  assistants,  whose  conversation  he  used  to  fol- 
low.    Notwithstanding,   however,   the  accurate  combination 
of  his  ideas,  which  constantly  enabled  him   to  play  at  cards 
with  his  comrades,  and  to  play  even  with  success,  Lecœur  had 
totally  lost  the  faculty  of  recollecting  proper  names.     In  fact 
he  could  not  tell  me  the  name  of  either  of  his  parents,  or  any 
of  his  friends — nay!  he  had  even  forgotten  his  own. 

A  remarkable  peculiarity  presented  itself,  likewise,  in  the 
optic  functions  of  the  right  eye.  The  patient,  whenever  he 
kept  his  head  still,  would  see  with  that  eye  only  the  horizon- 
tal half  of  any  objects  before  him,  or  in  other  words,  in  the 
axis  of  the  pupil  which  admitted  their  optic  cone.  Whenever 
they  digressed  from  this  axis  inwards,  and  beside  the  nose, 
they  became  by  degrees  fully  perceptible;  if,  on  the  contrary, 
they  removed  outwards  nearer  to  the  temple,  the  head  of  the 
patient  remaining  always  unmoved,  these  objects  would  disap- 
pear in  the  same  way,  although  a  part  of  the  cone  of  the  rays 
which  transmitted  their  form,  penetrated  still  through  the  pu- 
pil to  the  fundus  of  the  eye;  for  this  cavity,  as  well  as  the  mem- 
brane by  which  it  is  formed,  had  not  sustained  the  slightest 
Q 


122  Partial  Loss  of  Memory  and  Sight. 

alteration,  and  its  motions  were  performed  with  the  same  pre- 
cision as  those  of  the  left  eye. 

This  singular  phenomenon,  on  account  of  which  I  particu- 
larly introduced  him  to  the  Medical  Society  of  the  Faculty, 
seems  to  prove:  1.  That  the  retina  is  an  expansion  of  the  optic 
nerve,  because  the  weapon  had  not  injured  any  part  of  the  eye, 
the  root  of  that  nerve  excepted,  as  we  shall  learn  afterwards. 
2.  That  organs  of  different  kinds  have  not  merely  distinct 
properties,  but  that  those  very  organs  may  experience  partial 
alterations  in  their  functions.  3.  That  the  filaments  which,  in 
connexion  with  the  encephalon,  compose  the  nervous  truniis, 
have  a  distinct  origin,  and  receive  from  that  organ  a  particu- 
lar stimulus  in  proportion  to  the  functions  over  which  these 
elementary  filaments  preside. 

Notwithstanding  the  sensibly  ameliorated  condition  which 
our  soldier  had  attained,  he  v/as  distressed  to  see  himself  de- 
prived of  the  use  of  his  arm  and  leg.  However,  he  had  soon 
again  cause  to  be  rejoiced,  for,  upon  the  first  application  of  the 
mosa  to  the  anterior  cervical  pair  of  nerves  of  the  paralytic 
side,  he  felt  in  both  extremities  very  powerful  contractile  mo- 
tions, which,  under  the  influence  of  this  caustic,  I  caused  to  re- 
appear at  will.  This  phenomenon  greatly  surprised  the  assist- 
ants, and  made  the  patient  shed  tears  of  joy  and  affection. 
The  functions  of  the  muscles  of  the  face  were  likewise  gradually 
restored  by  means  of  several  moxas  applied  behind  the  right 
ear  and  over  the  passage  of  the  principal  branches  of  the  facial 
nerve. 

The  patient  walked  very  well;  he  began  to  promenade  in 
the  yards  of  the  hospital  and  even  in  the  streets;  for  two  months 
and  a  half  after  his  misfortune  he  repaired  on  foot  to  the  Medi- 
cal Society.  His  internal  functions  also  had  recovered  perfectly, 
when  he  was  almost  suddenly  taken  with  diabetes.  His  urine, 
on  being  analysed  by  Dr  Duponchel,  apothecary  to  the  hospital, 
precipitated  a  pretty  large  quantity  of  saccharine  principle.  I  be- 
lieve that  his  new  affection  had  been  in  a  great  measure  occasion- 
ed by  the  Spiritus  Mindereri  which,  in  doses  of  several  drachms, 
I  had  given  him  for  a  considerable  time,  in  pursuance  of  the 
opinion  of  the  physicians  who  recommended  it  in  such  large 


Partial  Loss  of  Memory  and  Sight.  123 

doses:  now,  as  there  scarcely  exists  a  more  powerful  diuretic,  it 
is  no  longer  doubtful  that  this  substance  had  too  highly  irritated 
the  secreting  urinary  organs  and  the  mucous  membranes  of  the 
digestive  viscera.  This  circumstance  justifies  the  maxim  of 
the  older  physicians,  who  recommended  the  exhibition  of  this 
remedy  only  in  small  doses  of  one  scruple  at  most;  and  it 
proves  besides,  as  I  have  had  occasion  to  notice  in  other  in- 
stances, that  the  proximate  cause  of  diabetes  consists  in  some 
kind  of  phlegmasia  of  the  kidneys  and  of  those  viscera  which 
maintain  a  sympathetic  connexion  with  the  former.  I  imme- 
diately prescribed  cooling  and  iced  mucilages,  dry  alkaline 
frictions  over  the  whole  surface  of  the  body,  and  scarified  cups 
to  be  applied  to  the  lumbar  regions;  and  I  should  afterwards 
have  made  use  of  the  moxa,  if  the  disease  had  not  yielded  to 
these  remedies.  In  fact,  from  the  seventh  day  all  the  symp- 
toms disappeared,  and  the  patient  was  once  more  in  a  satisfac- 
tory condition.  Of  the  paralytic  affection  which  had  existed 
before,  the  upper  arm  alone  remained  yet  under  its  influence 
and  imperfectly  performed  its  office. 

Meanwhile,  Lecoeur  waited  with  impatience  for  the  furlough 
of  convalescence  which  I  had  promised  him,  inordertogo  home, 
which  he  anxiously  desired  to  do,  when,  on  February  ISth,  a 
letter  from  his  brother  informed  him  that  a  woman  with  whom 
he  used  to  live  in  familiar  intercourse,  had  kept  a  considerable 
sum  of  money,  which  he  had  sent  him  to  defray  his  travelling 
expenses.  This  piece  of  newsmade  such  a  deepimpressionupon 
him,  that  at  the  end  of  the  meal  which  he  had  then  just  finish- 
ed, he  was  attacked  with  great  indigestion,  headach,  colic, 
repeated  vomiting,  and  soon  after  suddenly  with  stupor  and 
universal  numbness.  His  lower  limbs  were  ice  cold,  which 
the  application  of  artificial  heat  failed  to  obviate.  On  my 
visit  of  the  19th  I  instantly  ordered  the  whole  posterior 
surface  of  the  cranium  to  be  covered  with  a  large  blister, 
sprinkled  with  equal  parts  of  cantharides  and  camphor;  I  pre- 
scribed mild  injections,  some  antispasmodic  remedies,  and 
burning  hot  flannels  to  be  applied  over  the  entire  surface  of  the 
body.  The  disease,  however,  increased  rapidly,  and  all  the 
organs  of  sense  and  of  locomotion  became  paralysed.     The  pa- 


124  Partial  Loss  of  Memory  and  Sight. 

tient  made  his  urine  involuntarily,  and  it  may  be  stated  that, 
after  the  20th,  the  whole  life  of  relation  had  become  extinct; 
the  functions  of  the  internal  organs,  though  very  languid,  were 
preserved  till  the  night  of  the  21st  to  22d,  when  this  interest- 
ing man  expired,  which  was  the  third  full  month  after  the 
occurrence  of  the  accident. 

Post  mortem  examination.  — I  commenced  with  opening 
the  cranium,  where  I  found  all  the  vessels  of  the  dura  mater 
engorged  with  black  and  fluid  blood;  this  membrane  being 
raised,  I  perceived  on  the  superior  surface  of  the  brain,  a  thin 
layer  of  albumen,  blended  with  the  arachnoid;  on  the  internal 
surface  of  the  nasal  protuberance  (bosse  mammillaire)  of  the  os 
frontis  and  very  near  the  ethmoidal  groove,  I  noticed  a  transverse 
aperture,  about  three  lines  long,  and  one  in  diameter,  together 
with  a  separation  of  a  lamina  of  the  internal  table  of  the  bone, 
on  which  I  found  a  thin  layer  of  cortical  substance  of  the  brain 
adhering  to  the  circumference  of  this  aperture;  the  correspond- 
ing region  of  the  encephalon  displayed  a  concavity  analogous 
to  the  detached  cortical  portion.  From  this  concavity  there 
proceeded  a  canal  superficially  along  the  internal  margin  of  the 
summit  of  the  right  hemisphere,  as  far  as  the  level  of  the  con- 
cave margin  of  the  point  of  the  falx,  by  passing  over  the  ol- 
factory nerve  of  the  same  side;  it  crossed  the  space  of  sepa- 
ration of  the  two  hemispheres  and  penetrated  two  lines  deep 
into  the  substance  of  the  left,  by  passing  along  the  left  optic 
nerve  and  the  root  of  that  of  the  right  side.  This  root  had 
been  injured  by  the  point  of  the  instrument  near  its  origin  and 
beneath  the  anterior  cerebral  artery,  which  had  been  abraded 
there,  and  much  dilated;  finally,  the  extreme  end  of  the  foil 
had  been  arrested  at  the  inferior  wall  of  the  lateral  ventricle, 
very  near  the  left  branch  of  the  medulla  oblongata.  This  ob- 
lique canal,  which  might  have  been  from  two  and  a  half  to  three 
inches  long,  was  lined  with  a  layer  of  bloody  coagulum;  there 
was  not  the  least  vestige  of  suppuration.  We  found  only  a 
little  serum  of  a  'rosy  complexion  underneath  the  two  lobes 
of  the  left  hemisphere  of  the  brain,  which  extended  far  under 
the  cerebellum  and  into  the  vertebral  canal. 

The  thoracic  organs,  as  well  as  the  glandular  viscera  of  the 


Partial  Loss  of  Memory  and  Sight.  125 

abdomen,  the  liver,  kidneys,  and  pancreas  presented  nothing 
remarkable.  The  stomach  exhibited  no  disease  whatever;  the 
jejunum  had  become  inverted  in  three  different  places  to  the 
extent  of  two,  three  and  four  inches.  These  intus-susceptions 
were  recent  and  without  inflammatory  appearance.  Neverthe- 
less, the  ileum  was  found  inflamed  throughout  all  its  tissues; 
the  large  intestines  were  everywhere  filled  with  hardened  and 
convoluted  faeces. 

This  autopsie  examination  fully  justifies  the  prognosis  which 
I  had  established  respecting  the  nature  and  extent  of  the  injury 
of  the  brain.  It  shows,  besides,  that  lesions  of  this  organ, 
which  hitherto  were  always  looked  upon  as  mortal,  are  sus- 
ceptible of  being  cured.  That  of  Lecoeur  might  in  reality  be 
considered  so,  for  the  serum  effused  beneath  the  left  hemis- 
phere and  cerebellum,  had  doubtless  not  been  accumulated 
there,  until  all  the  vital  powers  of  the  patient  had  become  ex- 
hausted. This  much  is  certain,  that  the  blood  which  had  oc- 
cupied that  spot  in  the  beginning,  had  been  completely  absorbed, 
which  is  proved  by  the  walk  which  he  took  from  the  hospital  of 
Gros  Caillou  to  the  School  of  Medicine  and  back,  without  hav- 
ing experienced  the  least  deviation  of  his  intellectual  faculties. 
In  fine,  it  is  incontestable  that  the  cause  of  his  death  must  be  re- 
ferred to  the  superficial  changes  of  structure  of  the  brain,  excit- 
ed by  the  moral  nostalgic  affection  to  which  he  was  predisposed 
no  doubt,  in  consequence  of  the  effects  of  the  injury  and  the 
intus-susception  of  the  intestines.  The  latter  disorder  might 
have  had  another  cause  also  in  the  immoderate  use  of  ardent 
spirits  which  the  patient  clandestinely  procured.  Yet,  could 
it  not  have  been  brought  on  by  the  paralysis  which,  during 
the  latter  stage,  had  affected  the  superior  parts  of  the  digestive 
organs,  which  receive  undoubtedly  their  stimulus  from  the  brain 
through  the  medium  of  the  pneumo-gastric  nerves;  whilst  those 
of  the  life  of  relation,  or  the  ganglionic  system,  having  become 
irritated  by  the  presence  of  more  or  less  acrid  matter  in  the  in- 
ferior portions  of  these  viscera,  might  have  established  there 
an  anti-peristaltic  action?  Indeed,  the  invaginations  had  been 
formed  at  the  inferior  extremity  of  the  jejunum,  from  whence 
they  extended  upwards  to  its  superior  end. 


126  Curability  of  Injuries  of  the  Brain. 

The  followins:  fact  will  contribute  likewise  to  confirm  the 
theory  of  the  possibility  of  curing  injuries  of  the  brain,  and 
prove,  besides,  that  the  meningeal  arteries  may  be  cauterized 
with  impunity,  if  owing  to  the  mechanical  cause  of  the  frac- 
ture, or  in  consequence  of  the  operation  of  trephining,  they 
should  have  been  opened.  This  case  will,  moreover,  make 
us  acquainted  with  some  other  phenomena,  relative  to  the  doc- 
trine of  venous  inhalation. 

Claude  L ,  aged  27  years,  a  private  of  the  second  regi- 
ment of  infantry,  was,  on  May  13th,  1815,  brought  to  the 
hospital  of  the  guards.  He  had,  in  a  duel  fought  on  that  day, 
received  a  sabre  wound  with  a  cutlass  (sabre  de  fantassin,  bri- 
quet), which  besides  the  soft  parts  of  the  right  temple,  had  cut 
off  a  portion  of  the  osfrontis,  the  entire  anterior  inferior  angle 
of  the  parietal  bone  and  a  small  corresponding  portion  of  the 
great  wing  of  the  sphenoid,  so  as  to  make  an  oval  piece  of  bone 
two  incheslongbyonein  width.  In  consequence  of  this  wound, 
the  external  lamina  of  the  dura  mater  had  been  cut  into,  and 
the  two  principal  branches  of  the  middle  meningeal  artery  had 
been  divided. 

The  subject  dropped  down  after  the  accident,  he  having  lost 
his  senses.  After  having  received  the  first  assistance  from  the 
surgeon  of  the  regiment,  he  was  carried  to  the  hospital,  where 
he  arrived  extremely  intoxicated,  and  bathed  in  his  own  blood. 
Notwithstanding  the  circumstances,  the  wound  was  dressed. 
After  extracting  first  the  detached  piece  of  the  cranium,  which 
was  still  held  by  a  few  fibres  of  the  temporal  muscle,  the  blood 
furnished  by  the  arteries  above  mentioned,  it  was  thought, 
might  be  arrested  by  means  of  compression  with  tampons  of 
charpie;  but,  several  days  later,  after  suppuration  had  already 
commenced,  secondary  hemorrhage  supervened  with  renewed 
force.  This  accident  occurred  during  my  visit  of  the  19th 
instant.  I  gently  took  off  the  dressing  and  touched  the  osse- 
ous channels  of  the  parietal  bone,  in  which  the  two  ruptured 
arteries  lay  concealed,  with  a  small  iron  rod,  curved  backwards, 
and  heated  to  incandescence,  whereby  the  hemorrhage  was 
instantly  arrested.  The  patient  was  not  at  all  sensible  of  the 
application  of  the  red-hot  iron,  though  we  introduced  it  to  the 


Actual  Cautery  of  the  Meningeal  Arteries.         127 

(Icplh  of  about  three  lines,  between  the  dura  mater  and  the 
craniuna  upon  the  channels  above  alluded  to.  From  that  time 
the  dressings,  having  been  reduced  to  every  possible  degree  of 
simplicity,  were  made  with  safety  to  the  patient. 

Tlie  temporary  compression  of  the  brain  which  had  been  oc- 
casioned by  the  tampon  had  thrown  the  patient  into  a  state  of 
drowsiness;  without  its  being  productive,  however,  of  any 
symptom  of  hemiplegia.  Depletion  from  the  jugular  vein  and 
the  application  of  several  lanced  cups  to  the  nape  of  the  neck 
and  between  the  shoulders  dispersed  these  transient  symptoms 
of  an  engorgement  of  the  cerebral  vessels.  Subsequent  to  the 
cautery  he  became  composed,  the  wound  promptly  suppurated 
again,  and  all  the  other  functions  were  restored,  without  any 
apparent  obstruction.  In  short,  every  thing  promised  a  fa- 
vourable termination,  when  suddenly,  on  the  fourteenth  day 
after  the  accident,  symptoms  of  a  greatly  embarrassed  circula- 
tion made  their  appearance,  such  as  a  small  and  threadlike 
pulse,  with  a  marked  intermission  after  every  third  pulsa- 
tion. The  patient  experienced  a  kind  of  oppression  in  the 
praecordial  region,  the  very  slight  heavings  of  which  were 
scarcely  perceptible;  he  sighed  frequently,  and  complained 
of  a  troublesome  and  steady  heaviness  in  the  head,  which 
he  could  not  keep  in  an  elevated  position;  nevertheless,  his 
moral  and  sentient  faculties  had  been  preserved  inviolate;  he 
replied  correctly  to  the  questions  addressed  to  him,  and  fol- 
lowed extremely  well  the  thread  of  a  conversation.  The  dress- 
ings of  the  wound  gave  him  no  pain,  nor  did  he  feel  any  at 
other  parts  of  the  head. 

A  small  abscess  had  formed  near  the  opening  made  by  the 
lancet  (in  the  jugular  vein),  which  we  opened.  The  collec- 
tion of  matter  extended  over  the  whole  passage  of  that  vein, 
which,  however,  appeared  to  us  to  be  obliterated;  but  it  is 
probable  that  the  purulent  matter,  during  the  first  few  days 
of  the  formation  of  the  abscess,  might  have  entered  the  tube 
of  this  vein,  and  been  sent,  together  with  the  blood,  to  the 
right  auricle  of  the  heart.  The  fact  is  that  the  force  of  the 
circulation  had  progressively  declined;  pulse  and  heat  were 
entirely  gone,  while  the  patient  yet  spoke  and  urgently  de- 


128  Venous  Inhalation. 

manded  an  emetic  in  order  to  relieve  himself  from  the  weight 
which  constantly  oppressed  him  in  the  region  of  the  heart,  and 
where  he  constantly  kept  his  hand.  He  finally  died,  after 
several  convulsions,  in  the  night  of  the  29th  and  30th  of  the 
same  month. 

On  inspecting  the  corpse,  24  hours  after  death,  we  noticed, 
in  the  first  place,  a  complete  rigidity  of  the  extremities;  the 
countenance  had  a  marbled  appearance,  and  the  vessels  of  the 
conjunctiva  were  injected  with  blackish  blood. 

After  sawing  through  the  cranium  on  the  left  side,  we  no- 
ticed, in  removing  the  dura  mater  from  the  internal  surface  of 
the  bone,  that  the  portion  corresponding  to  the  opening  which 
had  been  left  after  the  sabre-wound,  was  covered  with  bony 
granulations  in  which  a  lamina  of  the  internal  table  of  the  pa- 
rietal bone  was  buried.  The  dura  mater  no  where  presented 
the  slightest  sign  of  inflammation,  not  even  where  the  actual 
cautery  had  been  applied  to  the  divided  extremities  of  the 
meningeal  arteries.  The  sinuses  of  that  membrane  and  the 
vessels  of  the  pia  mater  were  turgescent  with  black  and  fluid 
blood.  The  latter  membrane,  as  well  as  the  encephalon, 
showed,  likewise,  no  sign  of  inflammation.  The  lateral  ven- 
tricles contained  very  little  serum,  but  we  discovered  some, 
to  the  amount  of  about  three  ounces,  beneath  the  two  lobes  of 
the  cerebellum  and  in  the  spinal  canal.  The  substance  of  the 
brain  had  acquired  a  somewhat  greater  density  than  is  usually 
noticed  in  its  normal  state. 

Upon  opening  the  tliorax  we  found  the  lungs  pressed  down 
and  of  a  greyish  colour.  The  whole  substance  of  the  heart 
exhibited  one  large  mass,  so  as  to  fill  up  completely  the  cavity 
of  the  pericardium,  which  was  almost  entirely  destitute  of 
serum.  The  right  auricle  we  were  greatly  astonished  to  per- 
ceive filled  and  distended  with  an  albuminous  concretion  of  a 
yellowish  colour,  tolerably  solid,  and  extending  itself  by  a  thick 
pedicle  into  both  venae  cavae.  There  was  neither  blood  nor 
coagulum  in  either  ventricle,  while  on  the  contrary  we  found 
some  still  in  the  arch  of  the  aorta  and  about  the  origin  of  its 
principal  branches. 


Partial  and  Temporary  Loss  of  Memory.  129 

The  abdominal  viscera  presented  nothing  of  pathological 
interest;  even  the  liver  was  healthy. 

From  these  facts  it  will  clearly  appear,  1.  That  the  fall  of 
the  patient  in  cases  of  injuries  of  the  head,  as  we  believe  to 
have  demonstrated,  does  not  sensibly  affect  the  liver,  with  the 
exception  of  a  direct  shock:  2.  That  the  cauterization  of  the 
meningeal  arteries,  in  the  manner  in  which  we  have  done, 
did  not  and  cannot  occasion  any  unpleasant  effects,  and  that 
this  remedy  is  the  easiest,  simplest  and  safest  measure  for  the 
purpose  of  arresting  hemorrhage  from  those  arteries  which 
run  within  the  furrows  of  the  inner  surface  of  the  cranium: 
3.  That  the  death  of  the  subject  is  to  be  ascribed  principally  to 
the  obstacles  which  the  black  blood  has  encountered  in  the  pul- 
monary passages,  and  to  the  successive  and  gradual  cessation 
of  the  general  circulation.  This  is  what  induced  the  passive 
and  doubtless  inflammatory  engorgement  of  the  cerebral  vessels, 
as  also  the  extinction  of  the  vital  or  nervous  principle. 

But,  what  may  have  been  the  causes  of  the  formation  of 
these  albuminous  concretions?  We  were  informed  that  this 
soldier  used  to  take  ardent  spirits  in  large  quantities  and  that 
he  was  intoxicated  at  the  time  of  his  entering  the  hospi- 
tal. It  is  also  probable  that  he  may  have  succeeded  in  pro- 
curing some  during  his  illness,  and  whenever  he  found  him- 
self getting  better  from  his  wound.  Possibly,  some  puru- 
lent molecules  of  the  abscess,  formed  over  the  course  of  the 
jugular  vein,  might,  as  we  thought,  have  penetrated  into  its 
tube,  and  descended  into  the  auricle  in  such  a  raianner  as  to 
favour  the  formation  of  these  concretions,  aggravated  as  they 
were  no  doubt  by  the  use  of  ardent  spirits,  to  the  use  of  which 
the  patient,  at  least  before  the  accident,  had  been  given. 

Fifth  observation. — The  loss  of  recollection  of  the  substan- 
tive nouns,  or  the  incapability  of  pronouncing  them,  will  no 
doubt  in  some  instances  exist  only  for  a  short  time:  at  any  rate 
we  have  had  occasion  to  notice  that  circumstance  in  the  case 
of  one  Charles  Blanc,  a  private  of  the  second  regiment  of  in- 
fantry of  the  royal  guards.  This  soldier,  who  was  24  years 
old,  and  whose  frame  strongly  resembled  that  of  the  negroes, 


130  Partial  and  Temporary  Loss  of  Memory. 

had,  on  November  12th,  1821,  received  a  thrust  with  a  foil, 
behind  the  external  orbitar  apophysis  of  tlie  left  side. 

The  lounge  being  a  powerful  one,  had  affected  him  so  vio- 
lently, that,  whilst  rising,  after  the  fall,  which  had  instantane- 
ously occuiTed,  he  found  himself  deprived  at  once  of  speech, 
sight,  and  hearing;  and  he  had  evinced  some  symptoms  of  mental 
alienation.  A  strange  pain  in  the  head  had  become  developed, 
and  continued,  together  with  the  other  symptoms,  until  his 
admittance  into  the  hospital  the  next  morning,  which  determin- 
ed me  to  make  a  copious  depletion  from  the  right  temporal 
artery.  This  was  scarcely  accomplished,  when  he  experienced 
a  decided  relief;  his  senses  returned  partially,  and  the  intellect 
entirely:  the  features  of  the  face,  however,  and  his  looks  re- 
mained still  a  little  discomposed. 

November  \Sth. — There  was  afluctuating  tumour  and  a  sharp 
pain  at  the  orifice  of  the  puncture,  in  consequence  of  which  I 
dilated  this  small  wound.  The  temporal  artery  of  the  same 
side  having  been  divided  by  the  bistoury,  I  allowed  the  blood 
to  flow  for  a  short  time,  before  1  applied  a  ligature.  This  ef- 
fusion contributed  still  more  to  the  state  of  tranquillity  of  the 
patient,  and  accomplished  a  complete  restoration  of  his  senses. 
Four  or  five  days  afterwards,  no  other  clearly  marked  sign  of 
the  wound  and  its  consecutive  effects  remaining  beyond  the  cru- 
cial incision  which  had  been  made,  there  was  reason  to  expect 
that  this  improvement  w^ould  continue,  till  it  was  completely 
cicatrised.  But,  all  at  once,  the  appearance  of  symptoms  of 
gastric  derangement,  of  fever,  and  several  convulsive  motions, 
announced  the  existence  of  some  internal  irritation.  The  patient 
had  some  twitches  in  the  right  side,  and  experienced  an  inex- 
pressible feeling  of  uneasiness  at  the  epigastric  region  ;  the  appe- 
tite declined,  and  a  paralytic  condition  of  the  stomach  seemed 
to  have  been  induced.  The  senses  became  embarrassed  again, 
and  it  was  at  that  moment  that  Blanc  for  the  first  time  was 
observed  to  pronounce  neither  proper  names,  nor  substantive 
nouns.  It  was  surely  not  the  remembrance  of  these  words 
which  he  had  lost,  but  rather  the  faculty  of  articulating  them; 
for  if,  for  example,  somebody  asked  him  his  name,  he  imme- 


Injuries  of  the  Pariâtes  of  the  Cranium.  131 

diatcly  looked  for  the  ticket  lying  beside  his  bed,  and  showed 
him  the  name  written  upon  it;  if  some  pieces  of  money  were 
shown  him,  he  in  like  manner  specified  their  number  on  his 
fingers.     If  his  snuff-box  was  presented  to  him,  and  he  was 
asked  to  name  it,  he  seized  it  eagerly,  saying:  //  belongs  to 
me,  it  belongs  to  me.     This  reply,  so  little  analogous  to  what 
he  was  asked,  proves  moreover  an  occasional  alienation  of  the 
mind,  or  at  least  some  deficiency  of  intellect;  in  fact,  to  the 
various  questions  addressed  to  him,  instead  of  using  the  words 
"  It  belongs  tome,^^  which  in  preference  he  frequently  pro- 
nounced, he  ought  to  have  returned  under  all  circumstances, 
the  same  language  which  he  made  use  of  in  some,  and  answered 
thus:  I  cannot  say,  I  do  not  remember. 

For  the  purpose  of  overcoming  the  gastric  disorder,  a  gen- 
tle emetic  was  forthwith  directed;  the  lint  with  which  the  ori- 
fices of  the  incisions  were  covered,  was  spread  with  storax; 
scarified  cups  were  applied  to  the  shoulders  and  the  epigastri- 
um; and  finally  a  rigid  diet,  an  infusion  of  chamomile,  a  com- 
posingdraught  and  abolusof  camphor  and  nitre  were  prescribed. 
This  treatment,  which  was  pursued  for  several  days,  and  which 
was  afterwards  followed  up  by  the  application  of  a  moxa  over 
the  epigastric  region,  and  of  two  more  behind  the  ear,  over 
the  course  of  the  facial  nerve,  (nerf  petit  sympathique)  caused 
the  train  of  symptoms  which  had  come  on,  entirely  to  disap- 
pear. The  simple  phenomenon  of  the  forgetfulness  of  the  sub- 
stantive nouns  continued  to  the  same  extent  for  seven  or  eight 
days  longer;  hut,  at  the  end  of  that  time,  Blanc  began  to  pro- 
nounce his  name,  mine,  and  those  of  others.  He  forgot  and 
remembered  them  again  at  intervals.  At  length,  the  applica- 
tion of  several  moxas  sufficed  to  strengthen  his  memory;  for 
three  weeks  after  admission  into  the  hospital  he  was  discharg- 
ed, after  having  completely  recovered  that  faculty. 

Injuries  which  aflfect  the  parietes  of  the  cranium  may  give 
rise,  besides,  to  a  train  of  symptoms  different  from  those  last 
described.  Neuralgic  affections  of  a  more  or  less  decided  char- 
acter, may  be  the  consequences  of  fissures  of  the  internal  table 
of  the  bones,  of  laceration  and  inflammation  of  the  meninges, 
although  the  brain  itself,  and  the  functions  over  which  it  pre- 


1 32  Neuralgic  Affections  of  the  Head. 

sides,  shall  remain  inviolate,  particularly  when  the  inflamma- 
tion of  its  sero-fibrous  membranes  should  become  merged  in  that 
of  the  mucous  tissues  which  line  certain  cavities,  correspond- 
ing with  the  base  of  the  brain,  such  as  the  frontal  and  sphenoi- 
dal sinuses,  &c.  The  neuralgic  symptoms  will,  therefore,  be 
more  especially  observed,  after  injuries  which  have  occurred 
near  those  cavities,  and  still  more  so,  if  their  parieties 
should  become  involved  in  them. 

Though  their  primary  cause,  as  we  have  stated  just  now, 
consists  in  an  inflammation  of  the  membranes  above  alluded  to, 
yet  neuralgias  nevertheless  seem  to  originate  more  particularly 
in  acute  or  chronic  inflammations  of  the  nerves  arising  from 
the  brain  or  spinal  marrow.     They  are  ushered   in  by  smart, 
acute  and  shooting  pains  which  travel  along  the  course  of  the 
nervous  cords,  and  extend  as  far  as  their  more  or  less  remote 
branches.      These  pains  are  almost  always  accompanied  by 
convulsive  motions  of  the   corresponding  muscles,  by  an  in- 
crease of  sensibility  and  temperature  of  the  parts  aSected,  es- 
pecially at  their  accession,  which  is  attended  by  redness  and 
swelling.     These  various  symptoms  usually  have  their  inter- 
missions, according  to  the  changes  of  temperature,  theidiosyn- 
ci'asy  of  the  individuals,  their  age,  and  according  to   the  de- 
rangement of  some  habitual  discharges  to  w^hich  they  were 
subject,  &c.     Such  is  most  generally  the  career  of  neuralgic 
disorders  in  ordinary  cases;  in  others  they  present  an  infinite 
variety  of  anomalies,  according  to  the  diversified  genera  of 
nervous  affections;  but  we  do  not  know  that  there  have  been  as 
yet  observed  any  of  the  singular  phenomena  which  were  ex- 
hibited in  the  individuals  of  the  two  following  observations. 

A  young  grenadier  of  the  horse  guards  received,  during  a 
cavalry  maneuvre,  a  violent  kick  from  a  horse,  which  divided 
the  integuments  of  the  right  eye-brow  and  fractured  the  ex- 
ternal wall  of  the  frontal  sinus.  After  profuse  hemorrhage 
which  had  instantaneously  taken  place,  he  had  lost  his  con- 
sciousness and  the  use  of  all  his  functions  of  sensation  and 
locomotion;  but,  several  hours  later,  after  he  had  come  to 
again,  he  complained  of  extremely  acute  local  pains,  while 
convulsive  motions  were  perceptible  in  the  lips  and  jaw. 


Complicated  Neuralgix  of  the  Head.  133 

On  my  first  visit  I  freely  dilated  the  contused  and  lacerated 
wound  of  the  eye-brow,  and  afterwards  extracted  several  loose 
splinters  which  pressed  against  the  cavity  of  the  frontal  sinus. 
This  operation  facilitated  the  discharge  of  a  very  large  quantity 
of  black  coagulated  blood  which  had  become  accumulated  there. 
During  the  act  of  expiration  the  air  issued  from  the  wound, 
and  the  blood  immediately  afterwards  flowed  from  the  nose. 
After  the  dressing,  which  was  done  in  the  most  simple  manner, 
some  blood  was  taken  from  the  temporal  artery,  and  cups  were 
put  upon  the  nape  of  the  neck  and  between  the  shoulders; 
mustard  pediluvia  and  a  mild,  antiphlogistic  regimen  were  pre- 
scribed. During  the  first  few  days  the  mental  faculties  ap- 
peared to  us  to  be  disordered,  his  memory  was  gone  entirely, 
and  the  pains  continued.  The  patient  was  bled  again,  and  the 
use  of  diluents  was  persevered  in.  Notwithstanding  these 
measures,  symptoms  of  frenzy  manifested  and  developed  them- 
selves with  great  intensity;  and  fever  and  delirium  supervened. 
Soo'n  after  which  latter  symptom  a  lethargic  drowsiness  came 
on,  and  he  expired  in  convulsions  on  the  nineteenth  day  after 
the  accident.  During  all  this  time  he  seemed  to  us  to  have 
suffered  the  most  excruciating  pains  in  the  head:  the  dressings 
of  the  wound,  although  made  with  gentleness,  were  exceed- 
ingly painful,  and  caused  almost  always  convulsive  motions 
in  all  the  muscles  of  the  face,  neck  and  arm  of  the  sam.e  side, 
while  the  left  arm  was  benumbed,  and  threatened  with  pa- 
ralysis. 

On  examination  after  death,  we  discovered  a  most  intense 
inflammation  and  swelling  of  the  mucous  membrane  of  the 
frontal  sinus  and  of  the  nasal  fossse,a  scarcely  perceptible  fissure 
in  the  posterior  wall  of  the  sinus,  together  with  deep  seated 
inflammation  of  the  corresponding  portion  of  the  dura  mater 
and  a  sanguinolent,  serous  effusion  betwen  this  covering  and 
the  anterior  right  lobe  of  the  brain.  The  pia  mater  was  in- 
flamed likewise  to  a  great  extent  and  covered  with  suppurated 
spots;  the  substance  of  the  brain,  and  particularly  that  of  the 
right  hemisphere  was  dense,  and  the  vessels  going  into  it  were 
greatly  injected;  a  pretty  large  quantity  of  reddish  serum  was 
found   accumulated  in   the  ventricles.       The   mucous  mem- 


134 


Complicated  Neuralgise  of  the  Head. 


branes  of  the  larynx  and  pharynx  were  red  and  inflamed,  the 
bronchia  filled  with  reddish  mucus,  and  the  lungs  engorged 
and  of  a  brown  colour.  The  abdominal  viscera  were  healthy. 
The  rapid  career  of  the  inflammatory  and  nervous  symptoms 
had  at  first  inclined  me  to  the  belief  that  the  extreme  sensi- 
bility of  the  pituitary  membrane  had  chiefly  contributed  to- 
wards their  development;  but  the  following  case  has  proved  to 
my  satisfaction  that  their  principal  cause  should  be  referred  to 
the  fissure  in  the  internal  table  of  the  frontal  bone  and  to  the 
rent  of  the  fibrous  texture  of  the  meninges.  I  believe  never- 
theless that  the  inflammation  of  the  Schneiderian  membrane, 
through  its  sympathetic  influence  over  the  whole  system  of  or- 
ganic life,  has  largely  contributed  to  aggravate  that  of  the 
meninges,  for  we  found  again  in  the  air  passages  all  the  traces 
of  the  same  inflammation.  The  older  surgeons,  therefore, did 
not,  without  reason,  consider  the  injuries  of  the  frontal  sinuses 
as  most  serious,  especially  when  the  air  passed  into  the  nasal 
fossae;  and  it  is  consequently  on  that  account  that  they  recom- 
mended the  closing  up  of  such  wounds,  or  the  utmost  precau- 
tion in  order  to  prevent,  as  much  as  possible,  the  contact  of 
the  external  air  with  the  fine  and  exquisitely  sensible  mem- 
brane of  the  intricate  cavities  of  the  sense  of  smell. 

The  subject  of  the  second  observation  is  one  James  Ray- 
mond, a  cuirassier  in  the  second  regiment  of  the  guards,  25 
years  old,  of  dark  complexion  and  vigorous  constitution.  He 
received,  on  January  21st,  1822,  while  engaged  in  cleaning  his 
horse's  hind  feet,  a  kick  from  him,  on  the  right  eye-brow  and 
over  the  passage  of  the  superior  orbitar  margin.  The  kick  had 
been  so  violent,  that  the  external  table  of  the  frontal  sinus  had 
been  shivered  to  pieces,  and  he  completely  fell  on  his  back 
and  occiput,  lost  his  senses  entirely,  and  lay  asstifi'as  dead  on 
the  ground.  A  profuse  hemorrhage  took  place  from  the  nose 
and  ears.  The  surgeon  of  the  regiment,  after  having  dressed 
him  temporarily,  had  him  sent  to  the  hospital,  where  he  ar- 
rived in  the  middle  of  the  night.  On  my  visit  in  the  morning 
he  was  still  unconscious,  with  his  head  turned  to  the  left;  the 
eye  of  the  wounded  side,  and  the  ecchymosed  eye-lids  which 
covered  it,  protruded  considerably.     A  tetanic  rigidity  had 


Complicated  NeuralgisB  of  the  Head.  135 

already  manifested  itself  along  the  whole  right  side  of  the  body 
of  the  patient,  who  moreover  was  taken  with  stupor,  icy  cold- 
ness, and  all  the  symptoms  which  betoken  a  speedy  dissolution. 
Duringmy  visiting  tour,  his  head  was  shaved,  and  embroca- 
tions of  hot  camphorated  vinegar  were  made  over  the  entire 
surface.  I  next  proceeded  to  dress  the  wound,  which  I  dilated 
freely  and  in  every  direction;  I  extracted  the  most  movable 
bony  splinters,  as  also  several  clots  of  blood  which  were  lock- 
ed up  within  the  sinus;  during  the  operation,  the  patient  lost  a 
good  deal  more  blood  from  the  nose  and  by  the  incisions  which 
we  had  made.  Scarcely  had  the  first  dressing  been  finished, 
when  Raymond  recovered  the  use  of  his  senses  and  his  reason; 
since  which  period  he  has  never  ceased  to  talk  like  the  rest  of 
the  patients  in  the  ward,  and  to  follow  with  sufficient  pre- 
cision, every  kind  of  conversation.  I  directed  diluents,  stimu- 
lating injections,  mustard  pediluvia  and  the  application  of  ice 
to  the  head;  in  the  course  of  the  day,  the  general  heat  and  the 
pulse  became  so  far  developed  that  the  surgeon  in  attendance, 
as  I  had  instructed  him  to  do  in  this  case,  judged  it  advisable 
to  bleed  him  copiousl}'  from  the  arm.*  In  spite  of  all  these 
remedies  which  were  repeated  during  the  following  days,  and 
notwithstanding  two  other  depletions,  the  one  from  the  tempo- 
ral artery,  and  the  other  from  the  arm,  the  same  excessive  pains 
continued  to  exist,  which,  at  the  time  of  the  lethargic  waking 
of  the  patient,  had  come  on  in  the  occiput,  and  in  the  direction 
of  the  wound;  and  which  were  not  quieted  for  a  single  moment, 
till  after  a  deep  incision  which  I  made  into  an  œdematous 
swelling  which  existed  at  the  right  side  of  the  occiput.  In  the 
mean  time  the  suppuration  of  the  wound  of  the  forehead  be- 
came abundant,  and  discharged  itself  in  a  great  measure 
through  the  nose;  the  eye  became  unloaded  and  the  ecchy- 
mosis  disappeared  gradually,  but  the  patient  found  himself 
deprived  of  sight  on  the  wounded  side. 


*  It  is  a  great,  and  sometimes  fatal  mistake,  to  bleed  immediately,  every  body 
that  has  had  a  fall  or  received  any  wound  or  injury.  Such  bleedings  augment  the 
state  of  collapse,  and  frequently  deprive  nature  of  the  few  remaining  resources 
to  re-establish  the  equilibrium  between  the  enfeebled  vital  functions. 


136  Complicated  Neuralgiœ  of  the  Head. 

From  the  fifteenth  to  the  twentieth  day,  after  several  small 
splinters  which  had  eluded  our  search,  had  been  discharged  by 
the  wound,  and  facilitated  its  cicatrization,  an  increased  ner- 
vous excitement  manifested  itself,  and  put  the  two  extremities 
of  the  injured  side  in  a  state  of  violent  contraction,  which  soon 
assumed  a  tetanic  character.  The  deep  seated  pains  which  the 
patient  steadily  experienced  at  the  whole  right  lateral  side  of 
the  head,  grew  so  intense  that  he  could  not  bear  the  slightest 
and  most  gentle  touch  of  that  part  of  the  body,  without  utter- 
ing screams,  accompanied  by  horripilations  and  convulsive 
motions.  I  directed  the  depletions  from  the  neck,  arm,  and 
foot  to  be  repeated  at  proper  intervals;  numerous  scarified  cups 
to  be  applied  to  the  nape  of  the  neck,  to  the  shoulders  and  the 
spinal  column;  the  ice  to  the  head,  and  the  mustard  pediluvia 
were  continued.  With  these  various  remedies  we  succeeded 
in  conducting  the  patient,  who  was  alternately  better  and 
worse,  to  the  forty-first  day,  at  which  epoch  the  tetanic  symp- 
toms of  the  two  affected  extremities  suddenly  increased.  The 
muscles  of  these  parts  swelled  prodigiously,  and  became  un- 
manageable. The  testicle  of  the  right  side  became  tumefied, 
and  caused  the  patient  acute  pain.  To  our  great  surprise,  the 
hair  and  whiskers  of  the  same  side  stood  erect,  and  the  least 
touch  or  cutting  of  the  smallest  num.ber  of  these  hairy  produc- 
tions, although  made  with  a  very  sharp  pair  of  scissars,  con- 
veyed excessively  painful  feelings.  This  experiment  has  been 
repeated  a  great  many  times  by  the  medical  officers  of  the 
hospital  and  by  other  phj'sicians. 

This  extreme  exaltation  of  the  animal  and  organic  sensibil- 
ity  of  every  tissue  of  the  afiected  side,  induced  me  to  think  that 
a  deep  fissure  in  the  right  occipital  region  must  have  occasion- 
ed a  rent  of  the  dura  mater  and  an  efi'usion  beneath  that  mem- 
brane and  over  the  tentorium  of  the  cerebellum,  or  immediately 
under  the  right  lobe  of  this  portion  of  the  brain,  extending,  no 
doubt,  as  far  as  the  commencement  of  the  spinal  canal,  whereby 
an  inflammation  might  have  been  produced,involving  the  origin 
of  the  corresponding  nerves  of  the  medulla  oblongata,  as  well  as 
that  of  the  nerves  of  the  medulla  spinalis  of  the  same  side,  em- 
bracing at  the  same  time,  the  neurileme  and  the  substance  even  , 


Neuralgise  from  Meningeal  Inflammation.        137 

of  their  trunks  and  principal  branches.    The  circumstance  of  all 

the  parts  of  the  opposite  side  remaining  undisturbed  must  de- 
pend upon  the  fact  that  the  medullary  fibres  in  the  parts  of  the 
encephalon  which  we  had  just  now  occasion  to  name,  do  not 
decussate  in  the  same  manner,  as  we  have  already  observed  in 
some  of  the  preceding  cases.  And  it  is  doubtless  owing  to  the 
circumstance  of  the  efiusion,  confined  as  it  was  to  these  parts, 
being  unable  to  rise  ashigh  as  the  superior  surface  of  the  cerebral 
lobes,  that  there  could  not  be  perceived  any  mental  alienation; 
the  recollection  of  the  substantive  nouns  alone  was  suspended 
for  some  time.  The  loss  of  sight  and  smell  of  the  side  affected 
seemed  to  us  to  depend  upon  the  direct  or  indirect  lesion  of 
the  nerves  appertaining  to  these  senses.  As  to  the  organ  of 
speech  the  functions  of  which  were  with  difficulty  performed, 
I  believe  that  the  existing  restraint  was  dependent  on  the  com- 
pression vvhich  the  great  hypo-glossal  nerve  of  the  same  side 
experienced  at  its  origin,  or  at  its  passage  into  the  posterior 
condyloid  foramina. 

More  difficult  to  explain,  is  the  painful  trichoma  of  the  hair 
and  whiskers  which  could  neither  be  touched  nor  cut  in  par- 
ticles ever  so  small,  without  giving  the  patient  the  most  lively 
pain,  accompanied  by  horripilations,  convulsive  motions,  and 
sweats.  Can  the  substance  of  the  hair  itself  be  a  conductor  of 
animal  and  organic  sensibility?  that  seems  impossible!  or  can 
it  be  owing  to  the  shock  occasioned  by  the  percussion  they 
undergo  from  the  scissars  which  cut  them,  or  from  the  instru- 
ment which  touches  them,  and  which  impression  is  transferred 
to  the  bulb  or  root,  where  the  nervous  fibrillse  are  situated? 
this  appears  more  likely.  I  do  not  know  how  to  solve  such  a 
question:  to  the  physiologists  therefore  must  we  leave  it  to  in- 
stitute such  inquiries  as  will  lead  to  the  discovery  of  the  true 
cause  of  this  singular  phenomenon.  Nevertheless,  these  hairy 
productions  have  not  undergone  any  change  either  in  their 
form  or  thickness;  they  have  acquired  merely  a  somewliat 
deeper  shade  than  the  hair  of  the  left  side  of  the  head. 

I  had  expected  that  these  symptoms  would  not  have  any  other 
but  a  transient  existence,  and  that  they  would  promptly  yield 
to  the  general  and  capillary  depletions  vvhich  were  persevered 
S 


138        Neuralgiœ  from  Meningeal  Inflammation. 

in;  to  the  application  of  a  blister  over  the  whole  right  tempo- 
ral region;  to  several  applications  of  caustic  potash  to  the  nape 
of  the  neck  and  to  the  mastoid  region;  and,  finally,  to  several 
moxas  and  the  actual  cautery  which  were  equally  and  in  suc- 
cession applied  to  the  neck  and  to  the  anterior  part  of  the  right 
shoulder;  but  these  various  remedies  produced  no  other  than 
momentary  effects.  The  patient  never  could  bear  the  exhibi- 
tion of  narcotics,  not  even  in  the  smallest  doses.  I  wanted  to 
try  also  the  effects  of  the  cold,  or  nearly  cold  bath,  and  of  the 
prussic  acid,  latterly  so  highly  spoken  of  by  Professor  Tomma- 
sini.  The  bath  could  not  be  borne  at  any  temperature,  and 
the  use  of  the  distilled  water  of  the  cherry  laurel,  given  in  the 
dose  of  eight  to  ten  drops  at  most,  in  four  ounces  of  mucilage, 
caused  the  development  of  some  febrile  action,  violent  colic, 
and  a  bloody  dysenteric  discharge.*  I  suspended  its  employ- 
ment almost  immediately.  No  remedy  had  yet  succeeded  in 
subduing  completely  the  violent  inflammation  which  existed;  on 
the  contrary,  the  local  pains  increased,  towards  the  middle  of 
March,  to  such  a  degree  that  the  patient  maintained  that  the 
bones  of  the  cranium  were  drawn  asunder  as  if  by  a  pair  of 
pincers:  the  tetanic  contraction  of  the  muscles  advanced  to 
such  a  height,  that  the  extremities  of  the  fingers  buried  them- 
selves in  the  palm  of  the  right  hand,  without  any  one  being 
able  to  prevent  it,  the  trapezium  delineated  itself,  as  it  were, 
through  its  cutaneous  covering,  and  the  pectoral  muscles  of 
the  right  side,  swollen  and  contracted  as  they  were,  had  the 
appearance  of  a  considerable  tumour;  at  length,  the  increase 
of  sensibility  and  erectility  of  the  hair,  had  reached  so  high 
a  degree,  that  he  could  no  longer  bear  the  ice  upon  his  head, 
nor  any  other  kind  of  cataplasm.  It  became  necessary  to 
lay  every  thing  aside,  excepting  a  simple  retaining  bandage, 
loosely  applied,  as  that  of  Galen  for  example,  which  gave  him 
some  little  relief. 

Notwithstanding  this  state  of  suffering,  during  which   he 
nevertheless  continued  to  improve,  by  means  of  the  general 


*  Having  since  tried  this  remedy  repeatedly  in  the  same  doses  and  with  the 
same  intentions,  it  has  in  this  individual  invariably  produced  the  same  results. 


Neural gisa  from  Meningeal  Inflammation.         139 

and  topical  depletions  which  we  repeated  a  great  many  times 

(the  number  of  bleedings  amounted  to  thirty,  and  the  number 

of  scarified  cups  to  upwards  of  one  hundred),  by  means  also  of 

the  pleasant  mucilages  given  internally,  and  the  emollient,  and 

nearly  cold  baths,  this  soldier  had  retained  a  certain  freshness 

and  embonpoint;  because,  in  fact,  the  functions  of  organic  life 

had  never  been  disturbed,  save  by  the  momentary  action  of  the 

prussic  acid.     It  was  in  this  situation  that,  on  April  26th,  1822, 

we  presented  him  to  the  Medical  Society  of  the  Faculty  of  Paris, 

where  the  above  mentioned  experiments  were  repeated.     The 

cutting  ofFof  several  hairs,  although  it  was  done  with  excellent 

scissars,  and  unknown  to  the  patient,  was  equally  accompanied 

by  horripilations,  convulsions,  and  some  kind  of  painful  tremors 

which  spread  over  all  the  contracted  parts  as  far  as  the  extreme 

ends  of  the  fingers  and  toes,  which  were  doomed  to  endure  a 

very  troublesome  pricking  sensation. 

When,  at  length,  copious  and  steady  sweats,  excited  by  great 
heat  of  the  body,  had  again  produced  a  slight  improvement  in 
the  symptoms,  Raymond  expressed  his  wish  to  leave  the  hos- 
pital. He  accordingly  went  out,  August  18th,  seven  months 
having  elapsed  since  the  occurrence  of  the  accident.  At  that 
period  I  observed  that  a  diminution  of  the  pains,  and  emacia- 
tion or  atrophy  seemed  disposed  to  succeed  to  the  tetanic  con- 
traction. This,  indeed,  is  the  course  which  nature  commonly 
pursues  in  bringing  about  the  organic  changes,  the  first  effects 
of  which  are  irritation,  acute  inflammation  and  hypertrophia, 
either  because  the  causes  of  excitement  have  ceased,  or  because 
the  nerves  have' lost  their  sensibility  in  consequence  solely  of 
the  long  continuance  of  the  inflammatory  condition  into  which 
they  had  been  thrown.  The  circulation  is  disturbed,  and 
lowered,  and  the  parts  sink  into  a  state  of  atrophy  which 
may  increase  gradually,  or  progressively,  according  to  the 
effects  of  this  retrograde  movement  of  the  circulation  and  ab- 
sorption. 

The  suspicions  which  we  had  entertained  on  account  of  the 
gradual  increase  of  the  atrophy  in  this  soldier,  had  actually  be- 
come realized,  when  an  additional  excitement  in  the  parts  still 
under  the  influence  of  tetanic  action,  being  occasioned  by  some 


140  Injuries  requiring  the  Trephine. 

departure  from  his  regimen,  compelled  him  to  return  to  the 
hospital  in  the  early  part  of  January  1S23,  The  testicle,  toes, 
hand,  fore-arm,  and  the  lower  portion  of  the  upper-arm  of  the 
right  side  were  almost  entirely  wasted  away.  The  nails  had 
attained  a  rough  and  crustaceous  shape  and  a  length  of  ahout 
eight  or  ten  lines:  but,  during  his  second  stay  at  the  hospital, 
this  horny  growth  fell  oflf  spontaneously,  and  made  room  for 
others  of  a  more  natural  formation.  This  effort  of  reproduc- 
tion was,  in  my  opinion^  a  sign  indicative  of  improvement. 
From  that  period,  sensibility  and  motioa  appeared  to  us  to  be- 
come developed  in  the  fore-arm  and  head  of  the  patient;  and 
some  time  later,  at  the  hotel  of  the  invalids,  where  we  had 
obtained  for  him  the  privilege  of  admission,  a  further  improve- 
ment occurred;  but  it  was  at  Charenton,  where  his  impatient 
and  wilful  disposition  had  prevailed  on  him  to  go,  that  all  the 
properties  of  the  diseased  limb  were  completely  restored  under 
the  influence  of  emollient  baths  and  of  affusions  of  cold  water, 
to  which  he  was  forced  to  submit,  and  which,  far  from  being 
injurious  to  him,  as  was  the  case  at  the  hospital,  proved,  on  the 
contrary,  eminently  serviceable. 

Till  now,  the  object  of  our  observations  has  been  to  point 
out  the  differences  which  exist  between  the  lesions  of  every 
essential  part  of  the  encephalon,  and  the  particular  phenomena 
which  are  characteristic  of  each  of  them,  with  a  view  to  be 
enabled  to  establish  a  correct  prognosis,  and  to  indicate  in  a 
more  or  less  exact  manner,  the  therapeutic  means  which  may 
be  adapted  to  them.  At  present  we  intend  to  proceed  to  the 
consideration, 

1.  Of  those  injuries  of  the  head  which  indispensably  require 
the  operation  of  trephining. 

2.  Of  those  on  the  other  hand  where  this  operation^  contrary 
to  the  assertion  of  the  majority  of  writers,  is  not  merely  useless, 
but  may  be  hurtful. 

3.  Of  what  is  proper  to  be  done  in  the  case  of  hernia 
cerebri. 

4.  Of  the  causes  of  abscesses  of  the  liver,  subsequently  to 
injuries  of  the  head. 

In  this  part  of  my  work  I  shall  add  but  little  to  what  I  have 


Injuries  requiring  the  Trephine.  141 

said  already  in  a  memoir  of  mine  inserted  in  the  fourth  vol- 
ume of  my  campaigns,  published  in  1817.  I  ?hall,  therefore, 
support  the  propositions  which  I  have  just  now  laid  before  the 
reader,  by  a  series  of  authentic  observations  which  I  have  col- 
lected with  the  utmost  care,  and  which  I  shall  introduce  in 
succession  with  every  possible  degree  of  brevity. 

First  Proposition. — The  trephine  is  indispensable,  when  in 
a  wound  with  fracture  and  shattering  of  the  bones  of  the  cra- 
nium the  fragments  are  displaced  or  driven  into  its  cavity,  in 
such  a  manner  as  to  infringe  upon  the  dura  mater  and  brain; — 
when  the  foreign  substance  which  has  been  the  cause  of  the 
injury  is  wedged  within  the  space  of  the  fragments,  or  when  it 
has  made  its  way  into  the  interior  of  the  cranium,  without  its 
being  moved  from  the  roof  of  this  bony  receptacle; — and  lastly, 
when  it  has  been  ascertained  that  there  is  a  circumscribed  effu- 
sion of  some  fluid  established  in  the  same  parts. 

Previously  to  performing  the  operation  of  trepanning,  it  is  of 
primary  importance  to  know  whether  the  symptoms  really 
exist,  which  characterise  a  lesion  or  compression  of  any  part  of 
the  encephalon.  One  of  the  leading  symptoms  is  paralysis, 
more  or  less  extensive,  of  the  parts  which  correspond,  or  are 
opposite  to  the  injury,  in  proportion  to  its  effects  upon  one  or 
the  other  region  of  the  brain.  These  symptoms  are  the  more 
readily  recognized  as  they  show  themselves  immediately  after 
the  accident,  and  become  gradually  and  progressively  develop- 
ed, unless  the  fracture  be  confined  to  the  anterior  wall  of  the 
frontal  sinuses  and  the  foreign  body  be  arrested  within  their 
cavities.  In  the  latter  case,  which  may  be  readily  distin- 
guished, the  invasion  of  the  symptoms  of  compression  will  be 
expected  in  vain.  It  will  not,  however,  in  that  case,  be  the  less 
requisite  to  expose  the  fracture  by  appropriate  incisions,*  to 


•  III  making  the  incisions,  tiie  lesion  of  the  branches  of  the  frontal  nerve  should 
be  avoided  as  much  as  possible,- or  if  this  cannot  be  done,  care  should  be  taken 
to  divide  th^ra  completely.  The  puncture  of  these  nerves  may  occasion  the  loss 
of  sight  in  the  eye  of  the  same  side,  and  sometimes  be  the  cause  of  tetanus,  while 
the  complete  section  of  these  nervous  cords  will  not  impede  the  functions  of  those 
which  are  appropriated  to  vision. 


142  Injuries  requiring  the  Trephine. 

apply  a  trephine  of  a  diameter  proportionate  to  the  extent  of 
the  walls  of  the  sinus,  so  as  not  to  exceed  its  limits;  and  to  ex- 
tract finally  the  foreign  substance.  The  same  rules  are  appli- 
cable, when  similar  bodies  have  insinuated  themselves  into  one 
of  the  fossae  of  the  superior  maxilla,  such  as  the  orbitar,  nasal 
and  zygomatic  fossae  and  the  maxillary  sinuses:  yet,  rough 
and  protracted  examinations  may,  under  such  circumstances,  be 
fraught  with  danger  to  the  patient,  forthey  might  produce  symp- 
toms even  more  serious  than  those  which  could  result  from  the 
presence  of  the  foreign  substance  in  these  cavities. 

There  are  yet  some  other  remarks  to  be  made  before  we 
decide  on  performing  the  operation  of  trepanning  on  any  one  of 
the  difierent  regions  of  the  cranium.  In  undertaking  it  with 
a  view  of  extracting  any  foreign  substance  that  may  have  made 
its  way  into  this  cavity,  this  substance,  as  we  have  said,  must 
lodge  interiorly  at  the  margin  of  the  passage  which  it  has  made 
for  itself;  for,  if  it  should  have  become  lost  in  the  parenchyma 
of  the  brain,  it  would  be  useless  to  search  for  it  at  all.  Even 
if  it  should  have  been  arrested  by  the  substance  of  bones,  pro- 
vided its  presence  there  do  not  threaten  the  life  of  the  patient, 
the  operation  should  be  deferred,  or  rejected  altogether.  Now 
where  the  foreign  body  do  not  or  cannot  injure  any  important 
organ,  if  its  extraction  cannot  be  conducted  without  violence, 
it  will  be  better  to  relinquish  it  to  the  efforts  of  nature, 
which,  setting  on  foot  a  necrosis,  attended  by  a  perceptible 
exfoliation,  or  by  means  of  decomposition,  accomplishes,  in 
the  end,  the  destruction  of  the  superficial  bony  circle  which 
retains  and  covers  it.  Having  subsequently  become  loose, 
and  being  gradually  expelled  its  prison,  by  the  development 
of  some  subjacent  vascular  action,  it  may  be  removed  with 
scarcely  any  assistance  from  art,  and  without  the  least  incon- 
venience. 

A  foreign  body  having  obtained  access  into  the  interior  of 
the  cranium,  and  remaining  fixed  at  the  place  through  which 
it  has  penetrated,  may  be  discovered  with  perfect  ease  by  the 
slightest  tap  of  the  probe.  We  may  be  deceived,  however,  and 
doubt  its  presence,  because  of  the  smallness  of  the  opening, 
which  pretty  frequently  occurs  under  such  circumstances,  es- 


Injuries  requiring  the  Trephine.  143 

pecially  if  the  foreign  substance  be  of  a  round  form,  like  a 
bullet,  or  any  similar  projectile.  The  explanation  which  we 
propose  to  give  on  that  head,  will  sufficiently  point  out  the 
possibility  of  the  passage  of  a  foreign  body,  and  put  surgeons  on 
their  guard  with  respect  to  such  an  occurrence.  The  osseous 
fibres,  at  the  moment  when  they  are  struck,  will, previous  to  their 
being  ruptured,  yield  and  bend  under  the  weight  and  pressure 
of  the  instrument  which  has  caused  the  injury;  but,  this  resis- 
tance being  once  overcome,  those  fibres  have  a  tendency  to 
return  into  the  straight  line,  and  to  approach  each  other  by 
converging,  in  consequence  of  which  they  diminish  the  open- 
ing through  which  the  foreign  body  had  been  enabled  to  enter, 
and  which  may  even  become  narrower  in  proportion  as  the 
elasticity  and  strength  of  the  textures  may  be  greater,  as  1 
have  had  frequently  occasion  to  notice  in  young  subjects.  In 
old  people,  on  the  contrary,  the  bones, -instead  of  bending  or 
yielding,  shiver  into  pieces,  and  the  projectile  can  only  sur- 
mount the  resistance  it  meets,  by  carrying  away  a  piece  equal 
at  most  to  one-half  of  its  diameter.  The  greater  or  lesser 
size  will,  however,  again  depend  upon  the  spongy  or  com- 
pact nature  of  the  bone;  when  of  the  former  condition,  the 
perforation  of  this  tissue  will,  most  frequently,  be  ejBected  with- 
out fracture. 

A  foreign  body  need  not  necessarily  remain  fixed  at  the 
place  through  which  it  found  its  way  into  the  cranium,  with- 
out rendering,  on  that  account,  its  extraction  from  it  impossi- 
ble. Thus,  if  a  body  which  has  been  thrown  with  force, 
strikes  against  the  walls  of  the  cranium,  it  may,  after  having 
passed  through  the  bony  substance,  by  following  its  parabole, 
run  between  its  roof  and  the  dura  mater  over  a  space  more  or 
less  extensive;  and  finally  stop  at  a  point  diametrically  oppo- 
site to  its  entrance.  In  such  a  case,  the  existence  of  which 
may  be  inferred  also  from  the  symptoms  of  compression  which 
invariably  show  themselves,  and  from  the  pains  which  the  pa- 
tient refers  to  some  place  more  or  less  distant  from  the  wound; 
the  only  point  is,  to  ascertain,  precisely,  the  presence  of  the 
foreign  body,  and  the  distance  at  which  it  is  lodged.  With 
that  object  in  view,  a  gum  elastic  sound  is  to  be  introduced. 


144  Injuries  requiring  the  Trephine. 

with  every  practicable  precaution,  through  the  aperture  in  the 
cranium,  and  is  to  be  pushed  onward  till  it  meets  the  foreign 
body,  which  maybe  recognised  easily  enough  by  its  resistance, 
and  by  the  inequalities  which  its  surface  most  usually  presents. 
By  measuring  afterwards  externally,  with  the  same  instrument, 
the  route  which  this  body  has  taken,  the  place  will  be  thus 
pointed  out  where  the  counter-opening  and  the  operation  of 
the  trephine  should  be  made.  This  idea,  to  which  the  results 
of  several  gun-shot  wounds  of  the  cranium  had  led  me,  struck 
my  illustrious  preceptor,  Sabatier,  with  so  much  force,  that 
he  has  quoted  it  in  the  first  volume  of  his  "  Médecine  opé- 
ratoire.^'' Besides,  here  are  the  facts  which  have  suggested  it 
to  me. 

A  soldier  had,  in  Egypt,  received  a  gun-shot  wound  on  the 
head.  The  ball,  after  penetrating  through  the  frontal  bone  at  its 
middle,  and  near  the  sinus,  had  travelled  obliquely  backwards, 
between  the  cranium  and  the  dura  mater,  and  passed  in  this  way 
over  the  whole  extent  and  on  the  left  side  of  the  longitudinal 
sinus  as  far  as  the  occipital  suture,  where  it  stopped.  Its  presence 
had  developed  the  whole  train  of  symptoms  of  compress- 
ion, without  our  being  able  to  fix  upon  the  resting  place  of  the 
foreign  body;  the  patient,  however,  continually  referred  the 
seat  of  pain  to  a  spot  diametrically  opposite  to  the  entrance  of 
the  ball,  which,  with  the  other  symptoms,  left  no  doubt  of  its 
being  lodged  in  the  interior  of  the  cranium.  I  contrived  to 
pass  a  gum  elastic  sound  through  the  hole  in  the  frontal  bone, 
and  succeeded  without  trouble,  in  reaching  the  ball,  which  I 
recognized  by  its  resistance  and  inequalities;  after  which  I 
measured  externally,  the  route  over  which  it  had  travelled. 
I  now  resolved  upon  cutting  down  to  the  point  of  the  cranium 
which  corresponded  to  the  situation  of  the  extraneous  substance. 
I  made  a  counter  opening  with  a  large  trephine;  a  pretty  large 
quantity  of  purulent  matter,  mixed  with  small  clots  of  blood, 
was  discharged,  and  enabled  me  to  seize  and  extract  the  bullet 
which  depressed  the  dura  mater,  and  compressed  the  brain. 
Nothing  further  opposed  afterwards  the  completion  of  the 
cure. 

During  the  campaign  in  Poland,  in  1806,  I  had  a  second 


Injuries  requiring  the  TVephine.  145 

time  occasion  to  make  a  similar  counter  opening.  A  ball,  after 
having  penetrated  through  the  left  parietal  boss  of  one  of  our  sol- 
diers, had  grazed  the  internal  surface  of  the  parietal  bone  in  an 
oblique  direction, and  lodged  abouthalf  an  inch  from  the  occipital 
suture.  The  introduction  of  a  small  gum  elastic  sound,  the  signs 
which  the  patient  gave,  and  a  slight  ecchymosis  appearing  on 
the  scalp,  which  had  been  shaved  in  that  direction,  determined 
me  to  cut  down  to  the  bone  by  making  a  crucial  incision.  A 
small  fissure  became  at  once  perceptible,  besides  which  there 
were  symptoms  of  compression  which  continued  to  increase. 
These  additional  motives  induced  me  to  apply  the  crown  of  a 
trephine  large  enough  to  cover  the  fissure.  I  discovered,  im- 
mediately beneath  the  piece  detached  by  the  instrument,  one 
half  of  the  ball  flattened  and  partiallv  incrusted  with  bone. 
The  dura  mater  was  separated  from  the  roof  of  the  cranium-, 
along  the  whole  course  of  the  ball,  which  corresponded  with 
the  concavity  of  the  scull;  a  pretty  large  quantity  of  black 
blood  issued  from  both  openings.  A  fortnight  subsequently 
elapsed  without  the  patient  experiencing  the  slightest  incon- 
venience, and,  like  the  subject  of  the  preceding  observation, 
he  would,  doubtless,  have  been  perfectly  restored  to  health, 
but  for  an  attack  of  hospital  fever,  to  which  he  fell  a  victim. 

These  two  cases  prove,  in  opposition  to  the  opinion  gene- 
rally admitted  by  authors,  that  to  search  after  foreign  bodies 
within  the  cranium  is  not  always  a  useless  nor  even  a  dan- 
gerous practice,  provided  that  it  is  done  prudently  and  with 
adroitness. 

If,  finally,  under  s^imilar  circumstances,  or  in  the  more 
simple  cases  of  which  we  have  previously  spoken,  the  opera- 
tion for  trepanning  be  deemed  necessary  as  to  the  point  of 
fact  itself,  it  is  yet  requisite,  before  undertaking  it,  to  know 
how  to  select  the  time  best  calculated  to  render  it  serviceable, 
and  to  discern  whether  the  period  elapsed  since  the  occurrence 
of  the  injury,  be  not  a  new  objection  to  its  being  performed. 
If  the  surgeon  is  called  to  a  patient  in  the  course  of  the  first 
few  hours  after  thé  accident,  he  ought  to  avail  himself  forth- 
with of  these  moments  in  order  to  perform  the  operation,  if  it 
should  be  indicated,  and  to  extract  by  these  means  the  foreign. 
T 


146  Injuries  requiring  the  Trephine. 

bodies  which  bear  upon  the  dura  mater  and  the  brain.  For 
then  there  is  every  reason  to  believe  that  the  symptoms  of 
inflammation  which  ordinarily  do  not  become  developed  till 
after  the  first  twenty-four  hours  from  the  time  that  the  injury 
has  been  received,  and  which  would  be  a  weighty  counter 
indication,  have  not  as  yet  made  their  appearance.  If  there 
be  ever  so  little  delay,  inflammation  supervenes,  from  which 
it  will  be  evident  that  the  trephine  can  be  applied  no  longer, 
without  its  being  productive  of  additional  irritation,  which 
even  would  be  increased  in  proportion  as  the  pericranium 
scraped  off  is  more  or  less  extensive,  and  the  crowns  more  or 
less  in  number,  as  also  in  proportion  to  the  possible  existence 
of  some  atmospheric  phenomena,  such  as  the  moisture  and  in- 
salubrity of  the  air.  The  membranous  portions  being  laid 
open,  undergo,  if  once  inflamed,  a  rapid  change  of  structure; 
and  it  is  a  rare  occurrence  if  they  be  not  very  soon  attacked 
with  gangrene.  We  have  witnessed  several  instances  of  this, 
which,  doubtless,  influenced  Desault  to  perform  this  operation 
no  more.  Acting  upon  the  rule  laid  down  by  us  just  now,  it 
will,  therefore,  be  necessary,  previous  to  the  application  of  the 
trephine,  to  wait  until  the  inflammatory  symptoms  are  dis- 
persed. The  presence  of  the  extraneous  substance  from  which 
the  effects  of  cerebral  compression  result,  is  less  dangerous 
than  the  trials  made  during  the  stage  of  inflammation  to  dis- 
lodge or  extract  it-  Again,  the  death  of  the  patient,  always 
unavoidable  whenever  inflammation  and  suppuration  are  ex- 
tensively established  in  the  membranes  of  the  brain,  or  in  the 
substance  proper  of  the  latter,  would,  if  the  operation  were 
performed  at  this  time,  take  place  with  even  more  despatch 
than  if  he  had  been  relinquished  to  the  sole  resources  of  na- 
ture. 

Had  we,  moreover,  any  desire  to  enter  into  the  details  of 
the  inconveniences  attendant  upon  the  operation  itself,  as  it  is 
commonly  performed,  we  should  speak  of  the  practice  of 
scraping  the  bones  as  one  of  the  most  serious.  For  the  mem- 
branes are  torn  by  it  far  beyond  the  spot  where  the  crown  is 
intended  to  be  applied;  it  provokes  or  augments  the  irritation 
of  the  neighbouring  tissues  by  destroying  the  osseous  ramifica- 


Injuries  requiring  the  Trephine.  147 

lions;  it  brings  on  a  necrosis  throughout  the  whole  extent  of 
the  denuded  bone,  and  it  is  commonly  the  cause  of  more  or 
less  serious  sympatlietic  disorders,  as,  for  example,  of  abscesses 
of  the  liver. 

Previous  to  the  use  of  the  rasp,  a  circular  incision  should  be 
made  v/ith  a  bistoury  through  the  pericranium  and  its  adhe- 
sions to  the  integuments,  after  which  this  portion  of  fibrous 
membrane,  thus  isolated,  will  subsequently  be  detached  with- 
out effort. 

But,  when  at  length  the  operation  is  finished,  a  piece  of  fine 
sponge,  previously  moistened  and  wrung  out  again,  should  be 
fixed  in  the  hole  made  by  the  trephine;  a  perforated  linen  rag, 
spread  with  cerate,  be  laid  over  the  borders  of  the  wound, 
with  soft  charpee  on  tlie  top  of  it,  after  which  it  should  be  cov- 
ered with  a  simply  retaining  apparatus,  such  as  the  bandage 
of  Galen.  The  balsam  of  Fioraventi  and  other  irritating  re- 
pellent lotions  should  be  thrown  out  of  surgical  practice. 
The  dressings  should  be  simple:  the  first  of  which  should 
not  be  taken  off  until  the  suppurative  matter  shall  have 
soaked  completely  through  all  its  pieces,  and  then  every 
proper  precaution  should  be  taken  to  shelter  the  wound 
from  coming  in  contact  with  the  cold  and  moist  air.  Care 
also  should  be  taken  to  promote  the  alvine  evacuations  by 
injections,  as  well  as  the  mucous  and  cutaneous  secretions,  in 
order  to  keep  off  irritation  and  congestions  from  the  wound, 
or  from  those  organs  which  are  susceptible  of  becoming  sym- 
pathetically disordered.  Diluent  mucilages  and  scarified  cups 
to  the  nape  of  the  neck,  to  the  dorsal  and  epigastric  regions, 
will  fulfil  this  indication  perfectly,  and  prevent  inflammation. 

We  now  propose  to  relate  some  facts  in  support  of  our  first 
assertion,  that  it  is  absolutely  necessary  to  extract  foreign  sub- 
stances by  whatever  means  in  our  power,  and  to  let  out  the 
fluids  effused  within  the  interior  of  the  cranium. 

First  Observation. — Peter  Auger,  a  fusilier  grenadier,  had, 
during  the  Austrian  campaign,  been  struck  by  a  ball  on  the 
right  temple.  The  projectile,  in  fracturing  the  corresponding 
squamous  portion  of  the  temporal  bone,  had  been  divided  mto 
two  portions,  one  of  which  had  penetrated  into  the  cranium, 


148  Injuries  requiring  the  Trephine. 

while  the  otiier  remained  buried  in  the  temporal  muscle. 
Symptoms  of  concussion  and  compression  immediately  ap- 
peared and  threatened  the  life  of  the  patient.  After  dilating 
the  wound  and  applying  ligatures  to  several  branches  of  the 
temporal  artery  which  had  been  divided,  I  laid  bare  the  whole 
of  that  portion  of  the  cranium,  and  soon  discovered  the  first 
fragment  of  the  ball,  which  came  off  of  its  own  accord.  I  next 
raised,  with  an  elevator,  a  splinter  of  considerable  size,  and 
was  fortunate  enough  to  seize,  with  a  pair  of  dressing  forceps, 
the  other  fragment  of  the  ball,  which  was  flattened  and  sunk 
deeply  between  the  dura  mater  and  the  cranium.  Aided  by 
this  accidental  trepanning,  a  pretty  large  quantity  of  black 
and  liquid  blood  was  discharged.  From  that  moment  all  the 
symptoms  subsided  and  dispersed  gradually;  and  the  space 
which  was  the  result  of  the  exfoliation  of  the  periphery  of  the 
opening  having  rapidly  diminished,  the  patient  had  perfectly 
recovered  before  the  expiration  of  the  forty-fifth  day.  The 
cicatrix  was  depressed,  and  the  pulsations  of  the  cerebral  arte- 
ries had  not  )'et  entirely  disappeared. 

Second  Observation. — During  the  battle  of  Witepsk,  in  1812, 
a  young  Russian  soldier  had  been  struck  by  a  biscayan  at  the 
frontal  region,  a  little  above  the  right  eye-brow;  the  ball  after- 
wards had  pierced  and  fractured  the  os  fjontis,  and  penetrated 
into  the  interior  of  the  cranium,  where  it  lodged  against  the 
apex  of  the  right  anterior  lobe  of  the  brain,  against  the  orbitar 
projection  of  the  os  frontis  and  the  internal  crista  of  the  same 
bone.  Notwithstanding  the  size  of  its  volume,  it  was  but  very 
little  perceptible  on  the  outside;  the  opening  to  be  perceived 
measured  no  more  than  three  or  four  lines  in  diameter;  the 
attempts  and  efforts  to  extract  it  had,  therefore,  proved  inef- 
fectual. 

When  1  saw  the  patient,  he  felt  a  sensation  of  restraint  and 
an  extremely  unpleasant  heaviness  in  the  head,  which  con- 
stantly obliged  him  to  sit  up  and  support  his  head  on  his  knees, 
for  whenever  he  raised  it  upv/ards  and  backwards,  he  would 
faint  away.  The  tap  of  the  probe  upon  the  visible  part  of  the 
foreign  body  convinced  me  that  it  was  an  iron  ball,  the  size 
.of  which  must  greatly  exceed  the  diameter  of  the  opening 


Injuries  requiring  the  Trephine.  149 

through  which  it  had  entered,  and  that  consequently  it  could 
onl}'  be  extracted  by  the  application  of  the  trephine. 

The  wound  of  the  integuments,  having  been  dilated  by  two 
longitudinal  incisions,  exposed  the  whole  circumference  of  the 
opening  into  the  frontal  bone,  upon  which  we  applied  three 
small  trepanning  crowns  which  communicated  between  each 
other  and  the  hole  made  by  the  biscayan;  after  cutting  off 
the  angles  of  bone  which  they  had  left  standing,  it  was  an 
easy  matter  to  extract,  with  a  strong  pair  of  forceps  and  an 
elevator,  the  iron  ball,  which  weighed  not  less  than  six  ounces, 
(and  which  has  since  been  deposited  in  the  cabinet  of  the 
School  of  Medicine  at  Paris.)  By  means  of  a  wooden  scoop 
we  evacuated  entirely  a  large  quantity  of  coagulated  blood, 
and  extracted  several  small  fragments  of  bone  which  proceeded 
from  the  fracture  of  the  superior  wall  of  the  frontal  sinus. 
The  vacuum.,  thus  resulting  from  the  loss  of  so  much  bony 
matter,  was  filled  up  with  a  portion  of  fine  sponge,  previously 
moistened  and  wrung  out  again,  and  held  by  a  thread  so  as 
not  to  suffer  its  internal  side  to  sink  below  the  level  of  the 
margin  of  that  large  opening.  The  borders  of  the  wound  were 
covered  w^ith  a  fine  perforated  linen  rag,  spread  with  cerate; 
soft  charpee,  compresses,  and  Galen's  bandage  completed  the 
dressing. 

From  that  moment  the  patient  found  himself  relieved,  and 
enjoyed  a  comfortable  sleep  for  nearly  two  hours;  however, 
towards  evening  he  had  some  heat,  fever,  and  a  smart  pain  in 
the  wound.  A  copious  depletion  was  made  from  the  vena 
saphena,  and  the  patient  was  put  upon  diluents  and  anodyne 
antispasmodics.  The  dressing  was  not  renewed  until  the 
fourth  day  after  the  operation,  at  which  time  every  part  of  the 
bandage  was  soaked  through  with  sero-purulent  matter.  The 
next  day  1  found  him  in  a  most  satisfactory  condition,  and 
without  the  least  disturbance  of  the  functions  of  sensation. 
Some  time  afterwards,  his  recovery  had  become  complete, 
with  the  exception  of  the  depression  near  the  cicatrix,  and  the 
vacuum  still  perceptible  on  account  of  the  loss  of  substance  of 
the  frontal  bone.  This  cure  was  announced  to  me  at  Moscow 
by  M.  Roussel,  the  surgeon-major  of  the  hospital. 


150 


Injuries  requiring  the  Trephine. 


Third  Observation. — In  the  same  battle  another  Russian 
soldier  had  been  struck  on  the  left  temple  by  a  leaden  ball, 
one  half  of  which  had  penetrated  into  the  cranium  and  become 
flattened  across  a  narrow  fissure  which  the  shock  had  produced; 
while  the  other  half  had  furrowed  the  temporal  muscle  as  far 
as  its  posterior  attachment  to  the  base  of  the  mastoid  process, 
where  its  career  had  been  arrested. 

At  the  time  when  I  saw  the  patient,  five  days  after  the  oc- 
currence, the  whole  right  side  was  palsied;  he  had  lost  the  use 
of  his  senses  and  was  in  a  state  of  continual  agitation.  The 
wound  of  the  temple  having  been  dilated,  and  the  place  of 
fracture  exposed,  I  discovered  the  course  which  the  lead  had 
taken  through  the  muscle,  and  extracted  it,  by  making  a 
counter  opening  first  at  the  place  where  the  foreign  substance 
projected.  I  next  applied  a  trephine  to  the  descending  portion 
of  the  wound,  very  near  the  spot  where  the  other  piece  of  lead 
was  wedged  in.  After  which  it  was  quite  easy  to  dislodge 
and  to  extract  it,  together  with  several  other  splinters  contigu- 
ous to  it.  There  was  also  a  quantity  of  blood  extravasated 
between  the  cranium  and  the  dura  mater,  which  I  let  out  ac- 
cordingly. 

The  patient  felt  relieved  at  once,  but  some  days  afterwards 
he  sunk  into  an  adynamic  state,  from  which  he  did  not  recover. 
It  is  evident,  that  if  the  operation  for  trepanning  had  been  per- 
formed sooner,  it  might  have  been  possible  to  save  him. 

Fourth  Observation. — A  private  of  the  ex-guards,  who  had 
been  wounded  at  the  battle  of  Moscow,  presented  to  us  nearly 
the  same  symptoms  as  the  individual  of  the  preceding  case. 
He  had  been  struck  by  a  ball,  which,  after  fracturing  the 
middle  and  posterior  part  of  the  right  parietal,  had  become 
fixed  between  several  pieces  of  bone.  The  fragments,  pro- 
pelled by  the  projectile,  had  been  forced  under  the  cranium. 
The  ball,  which  was  believed  entire,  had  passed  out  again 
through  the  same  opening.  It  was  thought  sufficient  simply 
to  dilate  the  wound  and  to  apply  a  common  dressing  over  it. 
As  the  symptoms  of  compression  progressed  so  slowly,  it 
was  supposed  that  the  patient  could  recover  without  an  opera- 
tion, and  depending  throughout  on  the  resources  of  nature, 


Injuries  requiring  the  ''trephine.  151 

the  trephine,  which  we  had  advised,  was  obstinately  rejected; 
however,  the  symptoms  went  on  increasing,  and  the  patient 
died  on  the  twenty-first  day.  The  autopsy  of  the  cranium 
detected  a  fourth  part  of  a  ball  and  a  splinter  imbedded  in  the 
dura  mater  and  the  corresponding  portion  of  the  brain,  wiiere 
a  pretty  extensive  ulceration  was  observed.  It  is  probable, 
that,  if  those  foreign  bodies  had  been  extracted  in  due  season, 
the  patient  might  have  been  saved. 

We  have  also  witnessed  some  analogous  cases  in  which  the 
operation  of  trepanning  was  likewise  not  ventured  upon  from 
an  apprehension  to  derogate  from  the  precepts  of  the  celebrated 
Desault,  who  looked  upon  it  as  mortal.  We  coincide  also  in 
this  opinion,  but  only  when  the  foreign  body  has  departed 
from  the  internal  face  of  the  roof  of  the  cranium,  and  pene- 
trated into  the  substance  of  the  bi'ain;  and,  we  repeat  again, 
that,  under  such  circumstances,  it  will  surely  be  better  to  re- 
linquish the  patient  to  the  "médecine  expectante,"  than  to 
venture  upon  any  attempt  at  searching  into  the  interior  of  this 
pulpy  organ. 

In  order  to  give  additional  strength  to  the  precepts  so  long 
established  in  our  mind,  as  may  be  seen  by  a  reference  to 
the  dates  of  the  foregoing  cases,  we  deem  it  incumbent  upon 
us  to  add  to  the  above  two  concluding  observations  which  we 
have  collected  quite  recently.  We  anticipate  that,  together 
with  those  already  recorded,  they  will  contribute  to  show 
clearly  that  if,  towards  the  end  of  the  last  century,  the  pro- 
portion of  injuries  of  the  head,  requiring  the  operation  for 
trepanning,  has  been  exaggerated,  it  has  been  latterly  too 
much  the  fashion  to  stigmatize  this  operation,  and  to  perform 
it  accordingly  too  seldom. 

Fifth  Observation. — John  Baptiste  Mossant,  a  cuirassier  of 
the  second  regiment  of  the  royal  guards,  twenty-six  years  of 
age,  attended  a  manœuvre,  at  the  Champ-de-Mars,  on  June 
11th,  1824,  when  his  horse,  which  was  newly  shod,  stepped 
abruptly  and  rudely  aside,  threw  him  down,  and  kicked  him 
violently  on  the  head,  in  consequence  of  which  the  bones  of 
the  cranium  had  been  fractured,  and  he  was  placed  in  the 
utmost  danger.     His  comrades  of  the  same  troop  of  horse  flew 


152  Injuries  requiring  the  Trephine. 

to  his  assistance,  but  found  him  senseless,  weltering  in  blood 
and  covered  with  dust.  Notwithstanding  their  doubts  about 
his  life,  they  hastened  to  raise  and  transport  him  instantly  to 
the  hospital  of  Gros  Caillou,  where  I  was  yet  engaged  in  making 
my  visiting  tour.  He  had  then  recovered  from  his  syncope, 
but  could  give  us  no  account  of  the  accident  which  had  just 
happened  to  him. 

After  he  had  been  undressed  and  lodged  in  a  separate  apart- 
ment, and  the  apparatus  necessary  for  the  dressing  being  in 
readiness,  I  directed  the  whole  head  to  be  shaved,  and  after- 
wards made  a  careful  examination  of  the  wound,  which  occu- 
pied, in  a  transverse  direction,  the  entire  superior  part  of  the 
right  temple.  The  integuments,  as  also  the  temporal  muscle, 
were  irregularly  divided  down  to  the  bone,  to  the  extent  of 
about  two  inches  and  a  quarter,  and  the  temporal  portion  of 
the  frontal  bone  was  fractured  and  splintered,  the  pieces  having 
sunk  inwards.  As  there  were,  however,  no  decided  symptoms 
as  yet  of  compression,  I  contented  myself  for  the  present  to 
dilate  the  wound  freely,  and  to  lay  open  the  whole  fractured 
portion  of  the  frontal  bonej  the  pericranium  covering  it  was 
circularly  divided  and  detached  from  the  bone  by  means  of 
the  rasp;  several  branches  of  the  temporal  and  frontal  arteries 
were  tied;  the  whole  wound  was  covered  next  with  fine  per- 
forated linen,  spread  with  cerate,  which  served  onl}'  to  keep 
the  angles  of  division  slightly  approximated;  charpee,  square 
compresses,  and  a  bandage  of  Galen,  completed  the  dressing. 
We  prescribed  venesection  from  the  arm,  acidulated  diluents 
with  ice,  the  application  of  sinapisms  to  the  feet,  and  of  ice  to 
the  head. 

On  my  evening  visit,  the  patient  being  much  agitated,  and 
the  pulse  still  full  and  vibrating,  I  bled  him  copiously  from  the 
jugular,  and  recommended  the  frequent  re-application  of  ice  to 
the  head,  as  well  as  the  liberal  administration  of  cooling  seda- 
tives. He  passed  a  restless  night,  and  the  surgeon  in  attend- 
ance bled  him  again  from  the  arm. 

On  my  visiting  him  in  the  morning  of  the  12th,  he  was 
comatose,  and  laboured  already  under  marked  hemiplegia  of 
the  left  side;  lying  on  the  injured  side,  he  was  at  times  in  a 


Injuries  requiring  the  Trephine.  153 

state  of  extreme  agitation,  endeavouring  to  tear  off  the  dress- 
ings witii  which  the  wound  was  covered.  His  ideas  were 
incoherent,  and  he  replied  with  difficulty  and  very  imper- 
fectly to  the  questions  addressed  to  him.  His  pulse  was 
small  and  exceedingly  languid;  counting  scarcely  forty-five 
pulsations  per  minute.  The  alvine  evacuations  were  sus- 
pended; the  abdomen  distended  with  flatus;  the  feet  habitually 
cold;  and  besides,  he  had  incontinence  of  urine.  The  dress- 
ings being  removed,  we  discovered  the  whole  wound  cleansed 
from  the  blood  with  which  the  evening  before  it  was  filled, 
and  were,,  thei-efore,  better  able  to  appreciate  the  nature  of 
the  fracture  and  of  the  indented  fragments.  We  noticed  dis- 
tinctly that  the  largest  of  them,  being  of  a  square  shape,  leaned 
against  the  roof  of  the  cranium,  beneath  the  fractured  margin  of 
the  frontal  bone.  A  very  small  quantity  of  bloody  fluid,  of  a 
blackish  colour,  escaped  through  the  superior  fissure  of  the 
fracture.  Several  attempts  carefully  made  by  us,  proved  that 
the  depressed  pieces  were  too  firmly  wedged  in  to  be  extracted 
without  the  operation  of  trephining,  and  as  we  were  convinced 
that  they,  more  or  less  extensively,  compressed  the  dura  mater 
arid  a  portion  of  the  right  lobe  of  the  brain,  in  such  a  manner 
as  to  endanger  the  life  of  the  patient,  we  hesitated  no  longer  to 
perform  this  operation  on  the  spot.  This  could  be  done  now 
the  more  easily,  as  the  wound  had  been  dilated  with  that 
intention  on  the  preceding  evening,  and  as  the  portion  of  bone, 
over  which  the  crown  was  to  be  applied,  had  also  been  scraped. 
I  selected  that  part  of  the  frontal  bone,  where  the  rays  of  the 
superior  transverse  fracture  united  themselves  to  that  which 
descended  towards  the  squamous  portion  of  the  temporal  bone, 
with  the  intention  to  meet  the  more  easily  the  piece  which 
had  been  depressed  in  that  direction. 

This  operation  was  soon  and  successfully  accomplished;  the 
fractured  piece  of  bone  being  extracted,  there  issued  from  it 
about  a  tablespoonful  of  black  and  fluid  blood,  which  had 
been  effused  between  the  cranium  and  the  dura  mater.  Now, 
as  soon  as  the  teeth  of  the  cylindrical  saw  had  encountered  the 
fracture  itself,  it  was  sufficiently  easy  to  separate  the  principal 
depressed  piece,  which  had  removed  under  the  cranium  for 
U 


154  Injuries  requiring  the  Trephine. 

several  lines.  During  the  extraction,  the  two  tables  of  this 
portion  of  bone,  which  are  held  together  by  their  diploë,  had 
become  disunited;  in  the  vitreous  table  we  observed  one  of  the 
furrows  of  the  middle  meningeal  artery  (artère  sphéno-épi- 
neuse),  the  laceration  of  which  had  doubtless  contributed  to  the 
extravasation  between  the  cranium  and  the  dura  mater,  to 
which  we  have  alluded  already. 

Scarcely  had  the  operation  been  finished,  when  the  patient 
experienced  an  immense  relief;  he  accurately  replied  to  the 
questions  which  were  put  to  him,  and  a  few  hours  later  the 
symptoms  of  hemiplegia  had  dispersed.  This  sudden  change 
in  the  cerebral  functions  has  appeared  to  us  very  remarkable; 
for  the  darahgement  of  the  dura  mater  and  the  brain  had  been 
deep  and  very  extensive,  and  the  depression  of  these  parts, 
upon  which  the  two  displaced  splinters  immediately  bore» 
amounted  in  our  opinion  to  several  lines.  Some  smaller 
splinters  of  a  triangular  shape  were,  also,  extracted  from 
the  periphery  of  the  opening  into  the  cranium.  We  made 
him  incline  his  head  for  the  purpose  of  discharging  all  the  ex- 
travasated  fluids,  and  for  the  loss  of  bony  matter  we  substituted 
a  fine  and  well  washed  sponge;  strips  spread  with  cerate  were 
placed  over  the  angular  borders  of  the  divided  integuments, 
and  the  dressing  was  completed  by  layers  of  charpee,  by  com- 
presses and  a  six-tailed  bandage.  Ice  was  again  applied  to  the 
head,  and  several  stimulating  injections  were  given  to  him; 
mucilaginous  diluents  with  ice  added  to  them  were  also  per- 
severed in.  The  pulse  having  risen,  gave  after  the  dressing 
fifty -five  to  fifty-six  pulsations  per  minute.  The  patient  com- 
plained of  burning  thirst  and  wanted  incessantly  to  drink. 
We  hold  ourselves  warranted  in  ascribing  this  phenomenon  to 
the  sympathetic  irritation  which  the  eighth  pair  of  nerves  had 
been  subjected  to,  in  consequence  either  of  the  lesion  of  the 
temporal  nerves,  or  perhaps  in  consequence  of  the  direct  or 
consecutive  compression  which  the  brain  had  momentarily 
sustained. 

On  visiting  the  patient  in  the  evening,  we  found  him  com- 
posed, enjoying  a  comfortable  rest;  Ave,  therefore,  made  no 
change  in  our  prescriptions.     However,  in  the  course  of  the 


Injuries  requiring  the  Trephine.  155 

night  he  had  several  fits  of  delirium  and  some  febrile  heat,  for 
which  the  surgeon  in  attendance  thought  proper  to  bleed  him 
a  fifth  time  from  the  arm. 

During  the  ensuing  day  nothing  untoward  occurred,  and  he 
seemed  steadily  to  improve.  On  the  third  day  after  the  opera- 
tion, the  dressing  was  taken  off,  when  it  was  already  bedewed 
with  a  pretty  large  quantity  of  bloody  serum.  A  perceptible 
pulsating  motion  which  had  not  manifested  itself  at  the  time 
when  the  trephine  was  applied,  had  become  developed  and 
made  us  even  apprehensive  of  hernia  cerebri  which  we  be- 
lieved to  have  prevented,  rather  than  subdued,  by  the  appli- 
cation of  fine  sponge  into  the  breach  of  bony  matter  and  by 
the  simple  and  seldom  repeated  dressings  made  without  the 
addition  of  spirituous  substances  and  aromatic  tinctures,  so 
highly  recommended  by  some  authors. 

After  the  fifth  day  we  allowed  the  patient  some  chicken 
broth,  but  continued  still  with  cooling  drinks  and  the  applica- 
tion of  ice  to  the  head.  The  latter  remedy  has  in  our  estimation 
most  efficaciously  contributed  to  prevent  the  inflammation  of 
the  fibrous  membranes  and  to  disperse  that  which  already  exist- 
ed. We  opened  a  pretty  considerable  abscess  which  had  formed 
in  the  substance  of  the  superior  eye-lid,  and  which  had  been  the 
result  of  a  small  fracture,  caused  by  contre-coup  at  the  external 
wall  of  the  frontal  sinus  of  the  same  side.  A  small  lamina  of 
bone  subsequently  discharged  itself  from  the  opening  of  this 
abscess,  which  afterwards  cicatrized  quickly  and  of  its  own 
accord. 

From  the  ninth  day  the  patient  was  out  of  danger,  and  ad- 
vanced in  fact  rapidly  towards  recovery.  A  great  many  small 
fragments  exfoliated  from  the  whole  periphery  of  the  trepanned 
and  fractured  parts;  the  margins  of  the  other  bony  pieces 
which  had  remained  sound,  approximated  each  other  by  be- 
coming thinner  in  such  a  manner  as  to  close,  though  incom- 
pletely, the  immense  chasm  which  the  trephine  and  the  exfo- 
liations of  bone  had  left  behind.  At  length,  by  the  first  of 
September  of  that  year,  the  wound  had  entirely  cicatrized, 
and  with  the  exception  of  a  somewhat  impaired  condition  of 
his  memory,  he  had  again  acquired  his  embonpoint,  and  en- 


156  Injuries  requiring  the  Trephine. 

joyed  good  health.     He  was  presented  to  the  Academy  of 

Surgery  at  its  last  meeting  in  the  month  of  August. 

After  this  statement,  it  certainly  can  no  longer  be  doubted 
that  the  cuirassier,  to  whom  the  accident  just  related  had  oc- 
curred, was  indebted  for  his  life  to  the  operation  of  trephining, 
which  in  his  case  had  been  performed  at  the  most  suitable  pe- 
riod and  on  the  most  favourable  situation.  We  believe,  there- 
fore, that,  under  this  consideration,  the  case  in  question  will 
not  be  destitute  of  interest. 

Sixth  Observation. — The  individual  of  whom  I  am  about 
to  speak  now,  was  infinitely  less  fortunate  than  Mossant. 
This  soldier,  of  the  name  of  James  Gabriel  Laroche,  was  a 
gunner  in  the  artillery  of  the  guards,  twenty-five  years  old,  of 
a  robust  constitution.  On  June  17th,  1824,  he  was  brought 
into  the  hospital,  on  account  of  an  attack  of  complete  hemi- 
plegia of  the  whole  left  side,  accompanied  with  some  deviation 
or  contraction  of  the  right  commissure  of  the  mouth.  He  was 
in  a  state  of  mental  stupor,  and  seemed  to  be  insensible  to  the 
action  of  every  external  stimulus.  When  asked  about  the 
origin  of  his  complaint,  he  would  reply  that  it  had  become 
gradually  developed,  without  his  being  able  to  assign  any 
cause  for  it.  After  having  examined,  however,  the  head  of 
this  soldier,  and  discovered  there  in  tlie  hairy  scalp,  on  the 
right  superior  side  of  the  forehead,  a  perpendicular  cicatrix  of 
about  one  inch  and  a  third  in  length,  which  at  its  external  mar- 
gin formed  a  bump,  painful  to  the  touch,  in  which  sensation  the 
whole  corresponding  region  participated  likewise,  he  informed 
us,  in  answer  to  our  renewed  questions  as  to  the  cause  of  this 
cicatrix,  that  six  or  seven  weeks  previously  he  had  received  a 
sabre  wound  on  that  spot,  for  which  the  surgeon  major  of  his 
regiment  had  attended  him.  The  edges  of  the  wound,  which 
had  tiie  appearance  of  being  a  deep  cut,  had  united  by  the  first  in- 
tention, that  is  to  say,  with  the  aid  of  adhesive  strips,  agreeably 
to  the  rules  laid  down  by  the  majority  of  authors.  Indeed, 
the  integumentary  edj^cs  had  in  the  course  of  a  ver}^  few  days 
formed  a  reciprocal  adhesion.  Before  the  ninth  day,  the  cica- 
trix was  completed,  so  that  the  patient,  on  the  belief  of  being 
cured,  returned  to  his  regiment  and  resumed  his  duties  which 


Injuries  requiring  the  Trephine.  157 

he  has  continued  to  perform  until  he  was  attacked  with  he- 
miplegia, five  or  six  days  previously  to  his  admission  into 
the  hospital. 

However,  the  bump  observable  on  the  temporal  surface  of 
the  cicatrix,  the  local  pains  with  which  the  least  touch  of  this 
part  was  attended,  and  the  paralytic  symptoms,  made  us  suspect 
the  presence  of  some  splinters  beneath  the  cicatrix  and  in  the 
interior  of  the  cranium.  Being  unable  to  receive  any  further 
explanation  on  this  point  from  the  patient  himself,  I  sent  for 
the  surgeon  who  had  dressed  him,  and  on  the  positive  assur- 
ance which  he  gave  me  that  the  wound  had  been  a  simple  one, 
without  cut  or  fracture  of  the  bone,  since  it  had  united  by  the 
first  intention,  I  gave  up  the  idea  which  I  entertained  at  first, 
of  laying  open  the  portion  of  the  os  frontis  which  was  con- 
nected with  the  cicatrix,  and  of  applying  the  trephine  in  order 
to  extract  the  foreign  bodies  which  appeared  to  me  to  com- 
press a  portion  of  the  right  hemisphere  of  the  brain;  yet  my 
first  opinion  still  prevailed,  seeing  that  there  was  complete 
hemiplegia  of  the  left  side,  languid  and  small  pulse,  a  some- 
what comatose  state,  and  a  very  sensible  diminution  of  the  per- 
spicacity of  his  senses,  as  well  as  of  the  sensibility  of  the  whole 
system  of  the  life  of  relation. 

When  at  last,  to  my  great  regret,  I  was  unable  to  perform 
the  operation,  I  endeavoured  at  least  to  fulfil,  by  other  depleting 
and  revulsive  remedies,  the  most  urgent  indication  which  pre- 
sented itself  I  immediately  opened  the  right  jugular  vein 
and  abstracted  two  large  porringers  full  of  black  and  carbonized 
blood,  which,  after  twenty-four  hours  repose,  I  directed  to 
be  followed  up  by  the  application  of  scarified  cups  to  the  temple 
of  the  same  side,  to  the  nape  of  the  neck  and  between  the 
shoulders.  Sinapisms  were  applied  to  the  feet  and  ice  to  the 
head,  with  diluents  internally.  Two  days  later  I  ordered  a 
large  English  vesicatorium  to  the  right  side  of  the  head,  and 
still  later  two  moxas  to  the  base  of  the  cranium  behind  the  right 
ear;  and  a  drain  was  finally  made  between  the  mastoid  apophysis 
and  the  inferior  sub-occipital  protuberance  of  the  same  side. 

The  symptoms  of  paralysis  gradually  dispersed,  and  I  had 
anticipated  to  have  saved  the  patient  by  this  treatment,  when  all 


158  Injuries  requiring  the  Trephine. 

of  a  sudden  two  abscesses  showed  themselves  under  the  clavi- 
cle of  the  same  side,  which  I  opened  by  means  of  the  caustic 
potash.  About  the  time  of  their  cicatrization,  and  in  conse- 
quence of  some  act  of  imprudence  on  the  part  of  the  patient, 
a  most  alarming  hemorrhage  took  place  from  the  internal 
jugular,  which  was  ulcerated  near  where  it  empties  itself  into 
the  sub-clavian  vein.  This  occurrence,  however,  was  not 
accompanied  with  any  disastrous  consequences;  the  wounds 
returned  to  their  former  sanative  condition,  and  the  patient 
for  several  weeks  did  pretty  well.  But,  sometime  afterwards, 
symptoms  of  hepatitis,  accompanied  with  an  obstinate  diarrhoea 
supervened  at  last,  and  reduced  him  to  a  state  of  marasmus 
which  terminated  in  death,  in  spite  of  all  the  remedies  which 
we  employed  in  order  to  conquer  this  twofold  affection. 

On  the  23d  of  August,  the  day  after  the  death  of  this  man 
(it  being  also  the  day  of  our  clinical  lecture),  we  proceeded  to 
open  his  body,  in  the  presence  of  Doctor  L  *  *  *,  and  of  the 
surgeons  of  the  hospital.  We  took  especial  care  to  saw  cir- 
cularly through  the  cranium,  in  a  line  of  demarcation  of  the 
base  to  the  cap,  so  as  not  to  encroach  upon  the  cicatrix  of  the 
soft  parts.  After  having  separated  these  parts,  we  discovered 
a  pretty  deep  groove  in  the  frontal  bone,  beside  which  and 
separated  from  it,  there  was  a  small  spot  of  dull  white  which 
belonged  to  its  solid  substance.  The  whole  extent  of  the  cut 
was  red  and  inflamed,  and  the  integuments  covering  it  parti- 
cipated equally  in  this  inflammation.  A  powerful  resistance 
of  the  vascular  adhesions  of  the  dura  mater  to  the  cranium 
was  experienced,  whenever  we  attempted  to  separate  them; 
within  the  cranium,  and  in  direct  relation  with  the  external 
cat,  we  moreover  observed  two  lamellae  of  the  internal  table, 
separated  from  their  diploë  by  several  lines,  and  depressing  in 
the  same  proportions  the  dura  mater,  and  the  subjacent  portion 
of  the  encephalon.  This  part  of  the  dura  mater  was  inflamed, 
thickened  and  interspersed  with  suppurated  spots;  the  pia 
mater  presented  the  two  first  mentioned  appearances  even  in 
a  still  higher  degree.  The  cortical  substance  of  the  brain  was 
in  the  same  part  softened  and  depress-ad;  there  was  very  little 
serum  in  the  ventricles,  and  the  remainder  of  the  brain  exhi- 


Injuries  requiring  the  Trephine.  159 

bited  nothing  of  pathological  interest.  The  thoracic  viscera 
were  in  a  sound  condition.  As  to  the  abdomen,  the  stomach 
and  the  intestines  were  in  a  phlogose  state,  and  the  sigmoid 
flexure  of  the  colon  displayed  some  slight  ulcerations.  The 
liver  was  much  enlarged,  and  its  parenchymatous  substance 
was  lined  with  suppurating  tubercles  and  small  abscesses,  three 
of  which,  situated  in  the  great  lobe,  were  of  the  size  of  a  hen's 
egg.  The  remainder  of  the  texture  of  this  organ  was  softened 
and  of  a  greenish  colour.  This  hepatic  disorder  had  evidently 
been  occasioned  by  the  sympathetic  irritation  of  the  fibrous 
membranes  of  the  head;  and  it  is  this  disease,  in  combination 
with  that  of  the  intestines,  which  was  most  instrumental  in 
causing  the  destruction  of  the  patient. 

This  fact  then  proves  in  our  opinion:  1.  That  the  operation 
of  trepanning,  if  made  in  good  season,  would  have  prevented 
these  derangements  and  doubtless  have  saved  the  life  of  this 
gunner.  2.  That  animal  sensibility  appears  chiefly  to  emanate 
from  the  superior  layers  of  the  cerebral  lobes.  3.  That  the 
proper  and  isolated  lesion  of  some  one  of  the  points  of  the 
hemispheres,  invariably  induces  a  paralysis  of  the  opposite 
side,  and  that,  if  there  have  been  observed  some  instances  in 
which  the  paralytic  affection  has  occurred  on  the  affected  side, 
it  is  owing  to  the  circumstance  that  the  cerebellum  of  the 
same  side  had  been  injured  at  the  same  time,  or  that  the  dis- 
ease of  the  hemisphere  of  the  brain  communicated  itself  to  the 
hemisphere  of  the  other  side.  The  explanation  of  these  phe- 
nomena we  have  given  already  in  a  former  part  of  this  work. 
(Seep.  96.) 

Seventh  Observation. — This  case  is  one  of  those  which 
incontestably  corroborate  the  assertion  set  up  by  ourselves,  as 
to  the  necessity  of  immediately  applying  the  trephine  in  all 
cases  of  fracture  of  the  bones  of  the  cranium,  combined  with 
sinking  of  the  fractured  pieces,  and  with  lesion  or  depression 
of  the  dura  mater  and  brain.  Some  regard,  no  doubt,  must 
be  had  to  anomalies,  or  to  some  particular  and  unforeseen 
cases  which  the  judgment  of  the  surgeon  will  know  how  to 
distinguish;  but,  they  can  never  invalidate  a  general  rule,  and 
this  case  will  prove,  moreover,  that  contrary  to  the  opinion  of 


160  Injuries  requiring  the  Trephine. 

the  older  surgeons,  the  operation  for  trepanning  may  be  per- 
formed fearlessly  over  the  track  of  the  branches  of  the  middle 
meningeal  artery,  which  in  consequence  of  a  fracture  had  been 
ruptured  in  the  individual  of  the  following  case,  who  was  a 
private  of  the  first  Swiss  regiment  of  the  Royal  Guards,  of  the 
name  of  James  Lehmann,  aged  32  years.  This  soldier  was 
brought  to  the  hospital  of  the  guards,  almost  moribund,  in  the 
morning  of  the  22d  January  1S26,  on  account  of  an  extensive 
wound  on  the  left  side  of  the  head,  immediately  below  and  a 
little  in  advance  of  the  parietal  boss  of  that  side.  The  wound, 
which  was  of  a  form  somewhat  rounded  and  tattered  at  its 
borders,  was  accompanied  v/ith  considerable  denudation,  with 
a  fracture  and  some  shattering  of  the  parietal  bone,  the  frag- 
ments of  which  were  depressed  and  sunk  to  the  depth  of  half 
an  inch  into  the  meninges  and  the  brain.  It  was  clear  that 
this  solution  of  continuity  was  the  result  of  some  contunding 
body  striking  the  cranium  forcibly  and  in  a  transverse  direc- 
tion, or  that  this  man  must  have  fallen  full  length,  or  from 
some  elevated  spot  with  a  swiftness  which  was  the  much 
greater  as  the  elasticity  of  his  organs  was  in  some  measure 
suspended,  owing  to  the  profound  intoxication  in  which  he 
was  at  the  time  of  the  accident,  and  of  his  admission  into  the 
hospital.  This  circumstance  prevented  the  patient  from  dis- 
closing to  us  the  mode  of  action  of  the  offending  body,  yet  we 
shall  carefully  describe  its  effects. 

He  had  lost  entirely  the  use  of  his  senses  and  of  his  reason; 
the  whole  right  side  was  palsied  and  the  two  limbs  corres- 
ponding with  the  wound  were  frequently  and  immoderately 
agitated.  The  commissure  of  the  lips  of  the  same  side  w^as 
drawn  firmly  towards  the  ear;  the  pupils  were  much  dilated 
and  deprived  of  their  motions;  a  bright  light  did  not  appear  to 
make  the  slightest  impression  upon  the  organ  of  sight,  and  he 
could  not  utter  a  single  word.  The  pulse,  being  small  and 
feeble,  gave  scarcely  45  to  46  pulsations  per  minute;  he  dis- 
charged his  urine  involuntarily,  and  bled  from  the  ear  of  the 
injured  side;  every  symptom,  in  short,  announced  an  early 
dissolution,  and  I  believed  the  patient  in  such  imminent  dan- 
ger, that  when  1  was  called  to  attend  him  (which  was  at  four 


ï 


Injuries  requiring  the  TVephine.  161 

o'clock  P.M.)  I  hesitated  for  a  few  moments  to  undertake 
any  operation  at  all.  However,  I  applied  the  trephine,  yield- 
ing to  the  advice  of  some  of  my  colleagues,  who  assisted  me, 
and  amongst  whom  was  Dr  Lodibert,  apothecary  general  to 
the  hospital  of  the  guards,  and  yielding,  besides,  to  my  own 
wishes  to  relieve  the  patient,  widiout  presuming  to  be  able  to 
save  his  life. 

The  head  having  been  shaved  entirely,  and  the   dressings 
being  in  readiness,  I  dilated  freely  the  lacerated  and  contused 
wound  of  the  soft  parts,  by  making  a  crucial  incision  to  within 
about  an  inch  of  the  boundaries  of  the  fracture,  which  was 
completely  laid  open  by  means  of  the  rasp,  of  which  I  made  no 
use  till  after  having  circularly  and   thoroughly  divided  the 
whole  pericranium,  and  the  deep  layer  of  the  temporal  muscle 
covering  the  circumference  of  the  fracture.     Several  branches 
of  the  temporal  arteries  were  tied,  and  the  remainder  of  the 
wound  was  cleansed.     We  now  perceived  a  piece  of  the  pa- 
rietal bone,  of  the  size  of  a  five  franc  piece,  fractured,  sunk, 
and  wedged  in,  in  such  a  way  as  to  prevent  the  application 
and  action   of  any  elevator  for  the  purpose  of  raising  and 
extracting  it.      1  then  selected  the  most  slanting  point  of  the 
extremity  of  the  fracture,  in  order  there  to  apply  the  crown  of  a 
trephine  so  as  to  come  in  contact  with  the  fracture  itself.     The 
trepanned  piece  being  detached,  a  good   deal  of  blood  was 
effused  through  the  opening;  after  which  I  immediately  raised 
the  depressed  fragments  with  an  elevator,  and  extracted  them 
with  a  strong  pair  of  forceps.     Two  splinters  of  the  internal 
table  lay  deeply  concealed  under  the  roof  of  the  cranium, 
which  rendered  their  extraction  difficult.     The  result  of  this 
was  a  circular  and  angular  opening  into  the  parietal  bone  of 
about  one  inch  and  a  quarter  in  diameter.     We  found  upwards 
of  two  ounces  of  blood  partly  coagulated  and  effused  upon  the 
dura  mater;  this  being  evacuated,  the  hemorrhage,  which  had 
never  stopped,  was  occasioned  by  the  ruptured  branches  of  the 
meningeal  artery.     The  dura  mater  being  strongly  depresse<f, 
no  longer  transmitted  the  motions  of  the  brain;  it  is  probable 
that  beneath  this  membrane  there  may  have  existed  also  ano- 
ther effusion  which  I  had  no  disposition  to  evacuate  by  inci- 
V 


1&8  Injuries  requiring  the  Trephine. 

sion,  as  advised  by  some  authors,  in  as  much  as  the  action  of 
the  air  upon  that  bruised  or  lacerated  and  exposed  portion  of 
the  brain,  might  have  accelerated  its  disorganization  and  been 
followed  by  a  deep  seated  and  fatal  suppuration.  By  preserv- 
ing the  integrity  of  the  dura  mater,  I  had  occasion  to  expect 
that  the  blood  which  was  extravasated  beneath,  would  be  ab- 
sorbed, and  that  the  depressed  portion  of  the  brain  would  more 
readily  develope  itself,  resume  its  vital  properties  and  return 
to  its  primitive  state;  I  therefore  confined  myself  to  the  pru- 
dent resolution  not  to  cut  into  this  membrane,  and  hastened 
to  stop  the  hemorrhage  from  the  meningeal  arteries.  Pressure 
and  styptics  would  have  been  hurtful  and  useless,  and  the  ap- 
plication of  a  ligature  to  these  vessels,  concealed,  as  they  were, 
in  the  hollow  grooves  on  the  internal  table  of  the  bone,  being 
of  course  impracticable,  I  did  not  hesitate,  as  I  had  done  in 
several  other  cases,  to  apply  an  iron  probe,  heated  to  incan- 
descence, to  the  orifice  of  these  arteries,  in  consequence  of 
which  the  hemorrhage  was  instantaneously  arrested.  This 
kind  of  cautery  is  not  attended  by  pain  or  any  other  incon- 
venience. The  two-fold  indication  being  fulfilled,  I  pro- 
ceeded to  dress  the  enormous  wound  itself.  A  slice  of  fine 
sponge,  moistened  and  wrung  out  again,  was,  first  of  all,  placed 
within  the  bony  ring,  so  as  to  fill  up  all  irregularities;  a  fine 
linen  rag,  perforated,  and  spread  with  cerate,  was  next  laid 
over  the  whole  wound,  whose  four  corners  were  approximated; 
layers  of  charpee,  compresses,  and  Galen's  bandage  completed 
the  dressing.  The  operation  had  scarcely  been  finished, 
when  the  patient  moved  his  right  hand,  and  pronounced  a  few 
words.  The  pupils  contracted,  and  his  senses  seemed  to  have 
partly  at  least  resumed  their  functions. 

Notwithstanding  this  favourable  change,  I  did  not  entertain 
the  least  hope  of  the  recovery  of  the  patient,  but  attended 
him  nevertheless  with  great  care;  he  v/as  put  upon  the  use  of 
cooling  mucilages,  and  I  directed  the  application  of  hot  sina- 
pisms to  the  feet,  ice  to  the  head,  and  venesection  from  the 
arm,  as  circumstances  might  require.  Indeed,  after  two  or 
three  hours  of  perfect  rest,  fever  having  come  on,  accompanied 
by  heat  and  burning  thirst,  he  was  bled  twelve  ounces,  after 


Injuries  requiring  the  TVephine.  163 

which  I  ordered  a  number  of  lanced  cups  to  be  put  upon  the 
nape  of  the  neck,  back,  epigastric  and  hypochondriac  regions. 
The  irritation  and  inflammation  which,  in  injuries  of  the 
head,   especially  if  they  are  combined  with  fractures  of  the 
bones  of  the  cranium,  fas  it  actually  happened  in  this  case) 
invade  the  membranes  of  the  brain,  transmit  their  eflects  sym- 
pathetically to  the  internal  organs,  which  become  thus  the  seat 
of  a  concomitant  inflammation,  for  the  removal  of  which  laxa- 
tives have  been  supposed  to  be  best  adapted:  but,  these  reme- 
dies are  better  qualified  to  keep  up  inflammatory  action,  and 
to  cause  its  development,  than  to  resolve  it.     We  have  conse- 
quently, never   made   use   of  them.      We  treat  these  sym- 
pathetic inflammations  as  if  they  concerned  exclusively  the 
organs  in  which  they  are  seated;  and  the  best  remedies  to  over- 
come them,  and  to  reduce  that  even  of  the  meninges,  are 
doubtless  scarified   cups  (which,  under  all  circumstances,  are 
preferable   to   leeches),  tepid  emollient   gelatinous    baths   if 
practicable,  and  mucilaginous  drinks  with  ice  added  to  them. 
I  have  constantly  derived  the  greatest  advantages  from  this 
mode  of  treatment,  with   which,    during   the  first  stage  of 
inflammation,   general  bleedings  if  required,  the  application 
of  ice  to  the  head  and  of  sinapisms  to  the  feet,  should  be  com- 
bined. 

But,  let  us  return  to  the  subject  of  our  observation.  On 
the  next  day,  January  23d,  the  patient  was  somewhat  improv- 
ed, and  could  reply  to  the  questions  which  were  addressed  to 
him.  However,  as  there  still  continued  some  symptoms  of 
plethora,  venesection  from  the  arm,  and  the  application  of  cut 
cups  to  the  epigastric  and  right  hypochondriac  regions  was 
repeated.  Ice  to  the  vertex,  and  cooling  drinks  were  also 
persevered  in.  The  dressing  was  not  taken  off  until  the  fifth 
day,  when  the  compresses  were  thoroughly  soaked  with 
purulent  serum.  For  the  sponge  we  substituted  perforated 
linen,  spread  with  cerate,  which  covered  the  wound  entirely; 
over  this  an  apparatus  similar  to  the  first,  was  applied,  and 
the  same  regimen  was  continued  until  the  ninth  day.  All  the 
symptoms  of  inflammation  and  of  traumatic  fever  having  by 
this  time  disappeared,  we  suspended  the  ice  and  allowed  him 


164  Injuries  requiring  the  Trephine. 

rich  broths,  instead  of  the  simple  chicken  water  to  which  the 
patient  had  been  till  then  restricted.  At  length,  to  our  great 
and  agreeable  surprise,  we  perceived  that  the  storm  was  ap- 
peased, and  we  began  to  entertain  some  hope  for  his  recovery. 
Our  zeal  and  attention  were  redoubled,  and  we  dressed  the 
wound  ourselves  daily,  until  the  process  of  cicatrization  com- 
menced; several  small  fragments  of  bone  exfoliated,  one  after 
another,  and  the  cicatrix  was  completed  on  the  2Sth  of  April 
ensuing,  it  being  the  ninety-sixth  day  after  the  accident  and 
operation. 

The  case  as  it  is  the  result  of  this  wound  presents  a 
depression  of  six  or  eight  lines  in  diameter,  at  the  centre  of 
which  there  is  a  gap  through  which  the  pulsations  of  the  brain 
may  be  felt;  this  gap  will  imperceptibly  diminish,  and  finally 
disappear,  at  least  to  a  very  great  extent.  The  same  occur- 
rence we  have  witnessed  in  other  individuals,  and  quite  re- 
cently in  J.  B.  Mossant,  an  invalid,  formerly  of  the  second 
regiment  of  cuirassiers  of  the  royal  guards,  who  was  the  sub- 
ject of  one  of  the  preceding  observations.  It  is  pretty  well 
ascertained  that  the  opening  made  by  the  trephine  is  closed, 
not  only  by  stretching  and  attenuating  of  the  osseous  fibres  and 
vessels  along  its  margins,  but  even  of  the  bones  of  the  corres- 
ponding portion  of  the  cranium  which  pursue  the  same  method 
of  concentration,  as  we  have  seen  and  propose  to  explain  in 
another  part  of  this  work  (Clinique  Chirurgicale,  Tom.  IL). 
The  reduction  of  the  cranium  occurs  alike  in  those  cases  of 
epilepsy,  which  have  been  treated  upon  the  revulsive  and 
specific  plan,  if  a  hypertrophic  state  of  the  bones  of  the 
scull  has  been  the  cause  of  it.  The  study  of  these  pheno- 
mena, which  have  never  been  observed  before  us,  cannot 
fail  to  present  objects  of  great  interest  to  physiologists. 

Eighth  Observation. — We  shall  conclude  the  account  of 
our  experience  on  the  results  of  the  operation  for  trephining  by 
a  summary  notice  of  the  following  case:  the  subject  of  which 
is  one  Caspar  Zwald,  a  corporal  of  the  eighth  (the  second 
Swiss)  regiment  of  infantry  of  the  guards,  aged  22  years. 
On  the  28th  June  1S2S,  about  6  o'clock  P.M.,  this  young 
man  had  been  engaged  in  playing  at  nine-pins  on  the  platform 


Injuries  requiring  the  Th^ephine.  105 

of  Montmartre,  near  a  wind  mill.  Believing  himself  in  dan- 
ger of  being  struck  by  the  ball  of  his  companion,  he  suddenly 
started  back  so  far  as  to  be  within  the  reach  of  the  wings 
of  that  mill,  where  he  was  as  soon  caught  by  the  corner  of 
one  of  them,  and  thrown  down  several  paces  from  it.  Here 
his  comrades  saw  him  lying  senseless  on  the  ground,  bathed 
in  his  own  blood,  which  profusely  issued  from  a  deep  wound 
at  the  top  of  the  right  temple,  as  well  as  from  the  ear  of  the 
same  side. 

With  great  difficulty,  he  was  finally  resuscitated,  but  un- 
luckily, for  the  accomplishment  of  this  first  indication,  they  used 
whiskey  for  that  purpose,  it  being  the  favourite  liquor  of  this 
class  of  soldiers  (Swiss).  After  having  put  a  handkerchief 
on  his  head,  he  was  brought  into  our  hospital,  where  he  ar- 
rived the  same  night,  in  a  state  of  sinking,  and  extreme  pros- 
tration. The  surgeon' in  attendance  confined  himself  to  direct 
his  head  to  be  shaved,  apply  a  simple  dressing,  and  to  pre- 
scribe cooling  drinks. 

At  our  visit  in  the  morning  we  discovered,  indeed,  a  stella- 
ted wound  about  one  inch  in  extent,  below  the  right  parietal 
protuberance;  in  the  centre  of  the  wound,  a  fracture  was  per- 
ceived, with  depression  of  splinters,  extending  far  down  under 
the  temporal  muscle  into  the  whole  substance  of  the  inferior 
margin  of  the  temporal  bone.  The  patient  was  dejected,  in  a 
state  of  drowsiness,  and  evinced^  already,  symptoms  of  paral- 
ysis, throughout  the  whole  side  opposite  to  the  wound;  his 
pulse  hardly  beat  45  or  46  times  in  a  minute.  The  examina- 
tion with  the  probe,  convinced  us,  likewise,  of  the  shattering 
and  sinking  of  which  we  have  spoken.  .  We  now  hesitated  no 
longer  in  exposing  the  whole  extent  of  the  frarture,  by  making 
a  crucial  incision  into  the  edges  of  the  wound.  It  commenced 
by  a  curved  and  transverse  line  on  the  process  of  the  parietal 
bone,  and  then  descended  along  its  angles  under  the  muscle 
already  mentioned  as  far  as  the  centre  of  the  temporal  fossa. 
Between  the  two  angles,  three  or  four  fragments  of  bone  of 
several  lines  in  diameter  were  felt,  each  having  sunk  deeply 
into  the  cranium,  and  riding  upon  one  another.  After  having 
bared  them  of  their  fleshy  adhesions,  we  made  some  ineffectual 


166  Injuries  requiring  the  Trephine. 

attempts  at  raising  them  up;  after  which  we  decided  upon  the 
application  of  one  or  two  trepanning  crowns  above  the  prin- 
cipal fracture,  so  as  to  raise  and  extract  these  pieces,  if  re- 
quired, through  the  opening  thus  made  by  them.     This  part 
of  the  operation  being  done,  a  very  large  quantity  of  black 
blood,  mixed  with  some  streaks  of  vermilion,  issued  from  the 
cranium.      We  seized  several  small  and  movable  splinters, 
near  the  trepanned  region,   but  could  not  extract  the  three 
principal  pieces,  which  were  driven  about  five  or  six  lines  into 
the  dura  mater,  in  consequence  of  which  the  latter  was  sensi- 
bly depressed  upon  the  brain.      A  second   crown   was  now 
applied,  which  we  brought  to  bear  upon  the  margin  of  one 
of  these  fragments;  it  was  easily  detached,  and  thus  facilitated 
our  raising  the  others,  two  of  which  were  found  to  have  pier- 
ced the  meninges,  and  penetrated  several  lines  deep  into  the 
proper  substance  of  the  brain.     The  extraction   of  these  last 
pieces  of  bone,  although  it  had  been  made  with  the  utmost 
delicacy,  was  attended  by  discharging  a  few  particles  of  the 
grey  substance  of  this  organ,  which  inclined  us  to  augur  un- 
favourably of  our  operation,  or  of  the  termination  of  the  dis- 
ease.     Two  branches  of  the  middle  artery  of  the  brain  having 
been  divided  by  the  fracture,  and  continuing  to  bleed,  we  ap- 
plied the  actual  cautery  to  their  mouths,  whereby  the  hemorr- 
hage from  these  vessels  was  instantaneously  arrested;  but  we 
were  surprised  to  see  a  profusion  of  black  blood  flowing  from 
the  diploic  substance.     The  hole  made  by  the  stylet  into  the 
external  table  of  the  bone  had  already  produced  a  jet  of  the 
same  fluid,  which  had  been  very  troublesome  during  the  ope- 
ration: this  blood  could  proceed  only  from  the  numerous  veins 
which  creep  between  the  two  tables  of  the  cranium  and  which 
in  young  subjects  are  considerably  dilated,  and  more  especially 
so  in  those  of  a  scrofulous  diathesis.     Having  assured  ourselves 
that  there  were  no  more  foreign  substances  in  this  part  of  the 
cranial  cavity,  after  having  cleared  it    from  some   clots    of 
blood  which  still  adhered  to  the  margin  of  the  bony  opening, 
and  after  having  cut  ofif  the  acute  angles  which  had  been  made 
by  the  application  of  the  two  trepanning  crowns,  we  proceeded 
to  dress  the  wound  after  our  usual  method,  which  consists 


Injuries  requiring  the  Trephine.  167 

in  filling  up  the  perforated  space  in  the  bone,  by  means  of 
a  piece  of  fine  sponge  moistened  previously  and  wrung 
out  again,  by  covering  the  lips  of  the  wound  with  fine  and 
perforated  linen  spread  with  cerate,  after  which  we  finished 
by  applying  fine  charpee,  square  compresses  soaked  in  cold 
and  weak  camphorated  vinegar,  and  finally  Galen's  ban- 
dage over  and  above  it.  The  patient  felt  relieved  and 
declared  not  to  have  suffered  from  pain  till  after  the  incision, 
which  we  had  made  at  first  into  the  integuments.  The 
pulse  had  become  developed,  and  Jiis  speech  was  much  less 
embarrassed. 

Having  taken  the  precaution  to  keep  the  patient  secluded  in 
a  chamber  to  himself,  we  prescribed  for  him  cooling  drinks, 
ice  to  the  head,  sinapisms  to  the  feet,  and  venesection  at  dis- 
cretion, which  the  medical  officer  on  duty  resorted  to  in  the 
evening.  He  passed  a  quiet  night,  without  any  disturbance. 
On  my  visiting  him  the  next  day,  he  was  in  the  most  satisfac- 
tory condition,  and  I  began  to  entertain  some  hopes  for  his 
recovery.  The  dressing  was  bedewed  with  a  rosaceous  serum; 
even  the  external  pieces  were  coloured  by  it.  Ice,  mucila- 
ginous drinks,  injections  and  sinapisms  to  the  feet  were  con- 
tinued. Some  little  heat  and  turgescence  having  manifested 
itself  towards  evening,  venesection  from  the  arm  was  re- 
peated, and  a  scarified  cup  was  placed  over  the  epigastrium. 

Until  the  fourth  day,  nothing  of  consequence  occurred;  the 
patient  had  no  pain,  his  sleep'was  tranquil,  and  every  thing 
went  on  well.  At  that  time  the  dressing  was  throughout  re- 
newed; when  the  sponge  was  removed,  that  part  of  the  dura 
mater  which  had  been  laid  open,  already  presented  fleshy 
granulations  of  a  healthy  aspect,  and  its  heavings  were  quite 
perceptible,  the  sponge  was  soaked  through  with  purulent  se- 
rum, and  it  seemed  that  there  was  no  longer  the  slightest  ves- 
tige of  effusion  within  the  cranium,  for  no  fluid  of  any  kind 
issued  out  of  it.  We  then  thought  ourselves  justified  not 
to  replace  the  sponge,  and  the  wound  was  dressed  simply  with 
fine  perforated  linen,  spread  with  cerate,  soft  charpee,  and  the 
other  pieces  above  mentioned. 

On  that  day,  according  to  the  report  of  the  medical  officer 


168  Injuries  requiring  the  Trephine. 

in  attendance,  our  patient,  who  had  been  visited  by  several  of 
his  comrades,  complained  of  pain  in  the  head  and  stomach,  and 
frequently  desired  to  drink.  During  the  following  night  he 
was  much  agitated,  and  his  sleep  was  often  interrupted  by  fits 
of  delirium.  The  next  day  we  found  him,  indeed,  in  a  state 
of  exacerbation,  the  whole  left  side  having  been  struck  with 
paralysis.  His  pulse  was  febrile,  the  skin  dry  and  hot,  and  he 
could  hardly  articulate  a  few  incoherent  words.  Pressure  on 
the  stomach  appeared  to  give  pain,  and  the  tongue  was  red. 
Suspecting  some  erors  in  his  diet  to  have  been  committed,  we 
inquired  of  the  nurses,  if,  agreeably  to  the  usage  of  soldiers,  he 
had  not  been  taking  some  ardent  spirits.  It  may  of  course  be 
expected  that  their  reply  was  in  the  negative.  After -this, 
we  stationed,  to  be  sure,  a  watch  near  him;  but  the  complaint 
progressively  increased,  and  he^died  on  July  5th,  about  4 
o'clock  P.M.,  the  eighth  day  after  the  occurrence  of  the  acci- 
dent.    Previou'sly  to  his  death,  he  was  seized  with  convulsions. 

The  day  after  the  next,  we  inspected  the  corpse.  After 
having  taken  ofif  the  dressing  which  covered  the  wound,  we 
observed  a  hernia  cerebri,  filling  up  the  opening  in  the  crani- 
um, and  forming,  on  its  external  side,  an  exuberant  growth  of 
the  size  of  a  small  hen's  egg;  it  was  of  a  greyish  appearance 
and  interspersed  with  injected  blood  vessels. 

Whilst  sawing  circularly  through  the  cranium,  below  the 
seat  of  the  disease,  an  intense  ecchymosis  was  discovered  to 
exist  in  the  left  temporal  region,  combined  with  some  attri- 
tion of  the  fleshy  fibres  of  the  temporal  muscle.  The  whole 
encephalon  was  exposed  in  the  next  place:  the  portion  of  which 
the  hernia  consisted,  w^as  produced  by  the  superior  margin  of  a 
lacerated  wound  of  the  two  substances  of  the  middle  lobe  of  the 
brain,  penetrating  as  far  as  the  medullary  centre  of  Vieussens 
to  within  one  or  two  lines  of  the  cavity  of  the  right  lateral 
ventricle.  The  parietes  of  this  cerebral  wound  were  irregu- 
lar, and  of  a  greyish  aspect;  the  remainder  of  the  encephalon 
was  softened,  but  without  any  characteristic  inflammation. 
The  middle  and  right  fossa  of  the  base  of  the  cranium,  on 
which  the  injured  lobe  rested,  was  covered  by  a  thin  layer  of 
bloody  coagulum,  which  showed  to  have  been  the  seat  of  a  con- 


Injuries  requiring  the  Tn^ephine.  169 

siderable  effusion,  and  which  must  certainly  have  been  evacu- 
ated during  and  after  the  operation  of  the  trephine;  there  was 
but  little  reddish  serum  in  the  four  ventricles  and  spinal  canal. 
The  part  of  the  dura  mater  which  corresponded  with  the  wound 
had  been  torn  in  two  places. 

The  thoracic  viscera  presented  no  morbid  appearance.  A 
pretty  large  quantity  of  fluid  of  an  alcoholic  odour  was  con- 
tained in  the  stomach,  the  mucous  membrane  of  which  was 
much  inflamed  and  interspersed  with  patches  of  a  brownish 
red,  especially  towards  the  pyloric  orifice;  the  intestines  were 
inflamed  likewise;  the  other  viscera  were  healthy. 

Remarks. — There  is- no  doubt  that  the  injury  of  this  soldier 
was  of  the  nature  of  those  which  may  be  styled  mortal,  par- 
ticularly if  we,  for  one  moment,  reflect  on  the  nature  and  mode 
of  action  of  the  offending  cause.  It  has  been  even  more  vio- 
lent in  proportion  as  the  winds  were  boisterous.  The  ecchy- 
mosis  which  we  encountered  at  the  temple  of  the  opposite  side 
proves  also  the  intensity  of  the  internal  concussion,  which,  in 
our  opinion,  is  another  cause  of  ramollissement  of  the  brain. 
However,  it  would  not  have  been  impossible  for  the  patient 
to  have  survived  this  dreadful  accident,  if,  on  the  one  hand,  he 
had  not  indulged  in  the  use  of  ardent  spirits,  as  we  have  rea- 
son to  believe  he  did,  and  if,  on  the  other,  we  had,  according 
to  our  own  precepts,  postponed  the  entire  removal  of  the 
first  dressing  to  the  seventh  or  ninth  day.  It  is  evident  that 
the  symptoms  of  intense  gastritis  must  be  laid,  of  course,  to 
the  ingestion  of  some  highly  irritating  substance,  entirely  out 
of  the  way  of  our  treatment,  as  the  patient  had  been  allowed 
only  mucilaginous  drinks.  Now  this  could  be  nothing  else 
but  distilled  spirits  which  the  Swiss  soldiers  had  brought  him 
probably,  as  is  their  cruel  custom  to  do  with  all  their  comrades 
treated  at  the  hospital,  whatever  may  be  the  precautions  of  the 
administration  to  the  contrary. 

This  concomitant  cause  must  necessarily  have  irritated  the 
brain,  the  injured  portions  of  which  contracted  some  degree 
of  erectility  or  bloatedness:  the  sponge  having  been  prema- 
turely withdrawn,  this  organ  no  longer  met  with  any  resist- 
ance; the  encephalocele  being  thus  produced,  has  caused  all 
W 


170  Injuries  requiring  the  Trephine. 

the  preexisting  fatal  symptoms  to  be  developed,  and  promptly- 
occasioned  the  death  of  the  patient;  which  proves  that  in  every 
case  of  extreme  danger,  like  the  present,  it  is  all  important, 
after  fulfilling  the  first  indications,  not  to  disturb  the  dressing 
for  some  time,  in  order  to  prevent  any  new  irritation,  as  well 
as  the  air,  from  coming  in  contact  with  the  internal  parts,  to 
make  the  patient  observe  a  rigid  diet,  and  to  follow  it  up  care- 
fully with  all  the  antiphlogistic  remedies  at  our  command. 
We  hope  this  clinical  fact  will  not  be  lost  upon  practitioners. 

Most  authors  have  denounced  the  practice  of  applying  the 
trephine  over  the  frontal  sinuses,  as  well  as  along  the  track  of 
the  meningeal  arteries,  on  account  of  the  uncertain  depth  of 
these  cavities,  and  on  account  of  the  aerial  fistulas  which  they 
conceived  to  be  the  invariable  result,  and  which  they  looked 
upon  as  incurable.  I  have  deviated  from  ihis  rule  in  two  cases 
of  fracture  of  the  parietes  of  these  sinuses.  The  trephine  was 
applied  without  much  difiiculty,  and  the  operation  succeeded. 

Francis  Berrard,  a  guide  to  the  army,  received,  during  the 
third  assault  upon  St  Jean  d'Acre  in  Syria,  a  gun-shot  wound 
at  the  right  frontal  sinus.  The  ball,  in  fracturing  the  external 
wall  of  the  sinus,  separated  into  two  pieces;  one  of  which 
passed  along  the  forehead,  ploughing  through  the  skin  to  the 
extent  of  half  an  inch;  the  other  made  its  way  into  the  sinus 
and  fractured  its  internal  wall.  This  accident  was  followed  by 
loss  of  consciousness  and  some  slight  symptoms  of  concussion 
and  compression. 

The  external  fracture  was  not  very  extensive,  and  could 
hardly  have  permitted  the  passage  of  one  half  of  the  ball.  As 
the  fragments  had  not  been  displaced,  I  was  under  the  necess- 
ity of  applying  the  trephine  over  the  sinus,  by  means  of  which 
I  succeeded  in  discovering  the  foreign  body,  as  also  a  fracture 
of  the  internal  wall  of  this  cavity:  I  extracted  the  lead  pretty 
easily  by  means  of  an  elevator,  besides  which  the  opening 
made  by  the  trephme  allowed  me  to  introduce  a  small  conical 
crown,  with  the  assistance  of  which  I  perforated  the  floor  of 
the  sinus  without  any  further  accident.  Between  the  cranium 
and  the  dura  mater  there  was  some  coagulated  blood,  which  I 
evacuated.     The  symptoms  subsided,  and  in  a  very  few  days 


Injuries  forbidding  the  Trephine.  171 

were  totally  dispersed.  The  margin  of  the  trepanned  orifice 
subsequently  exfoliated;  the  holes  were  closed  by  membra- 
nous matter,  and  the  cicatrization  of  the  external  coverings 
was  promptly  accomplished  without  any  aerial  fistula. 

An  analogous  case  occurred,  during  the  same  action,  in  the 
person  of  one  Fromentin,  a  grenadier.  Part  of  a  ball  had  in 
like  manner  entered  the  left  frontal  sinus.  The  external  wall 
had -been  reduced  to  fragments,  easily  to  be  separated;  but  the 
elevator  had  been  required  for  the  extraction  of  the  ball,  where- 
by the  functions,  deranged  by  this  accident,  had  recovered  their 
tone,  and  the  patient  was  restored  to  liealth  in  an  equally 
short  space  of  time  as  the  guide  already  spoken  of. 

Second  Proposition. — Concerning  the  discrimination  of  the 
cases  in  which,  notwithstanding  the  assertion  of  most  authors, 
the  trephine  is  useless,  and  even  hurtful,  and  treating  of  the 
measures  which  under  certain  circumstances  may  be  employed 
as  a  substitute  for  this  operation. 

Already,  while  considering  the  first  proposition,  we  have, 
among  the  most  weighty  exceptions  to  the  operation  by  trepan, 
pointed  out  those  cases  where  foreign  substances,  although 
introduced  into  the  cranium,  may  lose  themselves  in  the  paren- 
chyma of  the  brain.  A  similar  reserve  ought  to  be  maintained 
in  all  cases  of  fluids  effused  at  a  distance  from  the  roof  of  the 
cranium,  and  with  still  more  force  of  reason  in  such  cases  in 
which  the  seat  of  the  effusion  cannot  be  ascertained.  Not  less 
inadmissible  is  the  trephine  in  all  wounds  of  the  head,  compli- 
cated with  fracture  of  the  skull,  whatever  may  be  the  extent 
of  the  fracture  or  the  number  of  rays  departingfrom  it,  provi- 
ded that  the  bony  fragments  be  not  depressed,  and  no  foreign 
bodies  or  symptoms  of  compression  manifest  themselves. 
The  concussion  of  the  brain  is  mostly  not  so  great  in  extensive 
wounds,  attended  with  loss  of  substance  of  the  soft  parts  and 
fracture  of  tlie  bones  of  the  cranium,  because  the  effects  of  the 
shock  from  the  offending  cause  are  lost  in  the  external  parts 
affected,  especially  when  it  has  operated  in  the  diagonal  of  the 
cranial  vault.  Now,  therefore,  as  in  such  a  case  the  internal 
parts  are  not  molested,  absorption  of  the  effused  fluids  proceeds 


17^  Injuries  forbidding  the  Trephine. 

more  rapidly  ;  the  fractured  pieces  afterwards  gradually  re-unite, 
and  the  patient  recovers  by  the  unaided  exertions  of  his  own 
constitution;  hence  the  trephine,  without  doing  any  good,  can 
only  retard  the  cure.  Finally,  the  exhibition  of  the  following 
facts  will,  better  than  the  most  lucid  theory,  decide  upon  those 
cases,  where  the  trephine  is  not  merely  useless,  but  even  may 
do  mischief. 

First  Observation. — M.  *  *  *,  store  keeper  to  the  army^ 
whilst  at  Berlin,  in  May  1812,  had  been  thrown  down  by  one 
of  the  carriages  of  state,  which  had  been  going  at  a  most  rapid 
rate.  The  head  sustained  its  shock  on  the  cutting  edge  of  a 
large  stone;  the  skin  of  the  forehead  and  the  scalp  were  de- 
tached as  far  as  the  occipital  protuberance,  so  that  this  enormous 
flap  hung  down  over  the  neck  and  ears.*  The  cranium  was 
entirely  exposed,  and  in  some  places  deprived  of  its  periosteum. 
There  was  a  stellated  fracture  on  the  left  frontal  boss,  one  of 
the  rays  of  which  extended  to  the  parietal  bone  of  the  same 
side.  There  was  no  sinking  down,  or  displacement  of  the 
bony  fragments. 

The  following  day,  whilst  I  saw  the  patient  for  the  first  time, 
he  suffered  lively  and  incessant  pain;  he  was  delirious  and  de- 
prived of  his  reason,  and  had  nervous  twitches;  his  pulse  was 
tight  and  the  countenance  livid.  Preparations  had  been  made 
to  apply  the  trephine,  which  the  fracture  just  mentioned  seemed 
to  indicate;  but  we  suspended  it  for  the  present,  and  contented 
ourselves  with  simply  dressing  the  wound.  After  having  re- 
moved all  the  foreign  bodies  and  shaved  the  whole  external 
surface  of  the  flap,  we  made  several  incisions  into  its  substance 
near  the  base,  and  into  the  neighbouring  and  contused  parts 
of  the  pericranium,  for  the  purpose  of  facilitating  the  discharge 
of  the  fluids;  one  of  these  incisions  corresponded  with  the  frac- 
ture. The  wound  was  washed  with  warm  and  sugared  wine; 
the  flap  was  re-applied  and  kept  in  its  natural  position,  b}''  means 
of  some  adhesive  strips  and  a  fine  perforated  linen  rag;  several 

*  This  sort  of  wound  gives  an  idea  of  the  torments  which  the  savages  of  the 
interior  of  North  America  formerly  inflicted  upon  the  tribes  vanquished  in  the 
wars  which  they  reciprocally  made  upon  each  other. 


Injuries  forbidding  the  Trephine.  173 

layers  of  charpee,  compresses  and  Galen's  bandage  completed 
the  apparatus. 

The  disgorgement  produced  by  these  incisions,  and  the 
opening  of  a  vein  of  the  foot,  dispersed  towards  evening  the 
pain  and  delirium  and  quieted  the  system;  and  when  at  this 
time  new  symptoms  of  inflammation  supervened,  lie  was  once 
more  bled  from  the  jugular,  and  mucilaginous  drinks,  sedatives 
and  anti-spasmodics  were  prescribed.  Notwithstanding  these 
measures  he  was  much  agitated  during  the  two  ensuing  days. 
At  length,  the  intensity  of  the  symptoms  declined;  a  sero- 
purulent  discharge  made  its  appearance,  and  on  the  sixth  day 
the  first  dressing  could  be  taken  off.  The  flap  had  formed 
fresh  adhesions  in  many  places  and  suppuration  became  estab- 
lished. In  order  to  promote  the  separation  of  the  sloughs 
which  covered  the  edges,  a  perforated  piece  of  linen,  spread 
with  storax,  was  laid  over  them.  All  other  treatment  was  con- 
tinued as  before. 

Suppuration  became  now  very  abundant;  the  patient's 
strength  decreased,  and  he  was  attacked  with  adynamic  fever. 
We  prescribed  acidulated  mucilages  with  ice,  and  ordered  the 
whole  surface  of  the  body  to  be  rubbed  with  ice  cold  cam- 
phorated vinegar.  In  addition  to  the  above,  he  had  vomiting 
of  bilious  matter  and  an  involuntary  alvine  evacuation.  The 
auspicious  moment  was  employed  to  administer  an  emetic; 
consisting  of  one  scruple  and  a  half  of  a  strong  and  cold  infu- 
sion of  ipecacuanha,  and  one  grain  of  tartarized  antimony, 
which  was  followed  by  copious  vomiting  and  plentiful  and 
very  fetid  alvine  discharges. 

The  succeeding  night  he  had  an  increase  of  fever  with  deli- 
rium, and  a  fixed  pain  at  the  occiput,  towards  the  base  of  the 
flap.  The  application,  over  this  part,  of  two  scarified  cups 
removed  the  pain  as  if  by  enchantment;  however,  as  there 
remained  still  some  tension  in  the  nape  of  the  neck,  as  well  as 
some  constraint  in  the  motions  of  the  head,  we  directed  a  large 
blister  to  be  placed  over  it,  and  for  the  state  of  weakness  into 
which  the  patient  had  sunk,  we  prescribed  powdered  Peruvian 
bark,  in  an  infusion  of  Arnica  and  Serpentaria  Virginiana,  with 
an  addition  of  some  sulphuric  ether.     The  next  day,  it  being  the 


174  Injuries  forbidding  the  Trephine. 

nineteenth  after  the  accident,  the  patient,  who  till  then  had 
been  in  a  state  of  drowsiness,  recovered  the  use  of  his  senses, 
and  from  that  time  forward  continued  steadily  to  improve. 

The  wound,  being  of  a  vermilion  appearance  and  filled 
with  fleshy  granulations,  was  disposed  to  cicatrize,  which  pro- 
cess, however,  would  not  take  place  until  after  the  exfolia- 
tion of  several  small  bony  fragments,  and  of  one,  in  particular, 
which,  because  it  had  embraced  both  tables  of  the  bone,  had 
left  a  portion  of  the  dura  mater  exposed. 

Since  our  return  from  Russia,  we  have  had  occasion  to  see 
this  officer  again.  He  enjoyed  perfect  health,  but  has  remained 
bald,  and  lost  almost  entirely  the  recollection  of  proper  names. 
The  other  mental  functions  were  unimpaired,  and  seemed  to 
perform  their  office  with  precision. 

This  singular  fact  and  the  cure  itself  are  two  circumstances 
worthy  of  notice.  If,  in  conformity  wdth  the  opinion  of  wri- 
ters, and  that  of  many  physicians  who  saw  the  patient,  the  tre- 
phine had  been  applied,  there  was  every  reason  to  believe  that 
he  would  not  have  survived  the  operation.  Indeed,  it  is  pro- 
bable that  the  dura  mater,  which  no  doubt  had  been  already 
inflamed  ever  since  the  third  day  after  the  accident,  by  the 
fresh  exposure  and  irritation  from  the  trephine,  would  have 
been  promptly  attacked  by  gangrene. 

Second  Observation. — M.  Giraud,  major  of  engineers  of 
the  ex-guards,  while  superintending  the  vvorks  for  the  explosion 
of  a  mine  at  Moscow,  was  struck  severely  on  the  head  by  a 
large  fragment  of  stone.  One  of  its  sharp  angles  divided  the 
integuments  of  the  superior  and  posterior  part  of  the  cranium, 
and  caused  a  radiated  fracture  at  the  posterior  angle  of  the  left 
parietal,  and  at  the  superior  angle  of  the  occipital  bone.  The 
wound  measured  about  two  inches  and  a  half  in  extent.  He  did 
not  fall  after  the  accident;  nor  did  he  lose  his  consciousness; 
but  was  sensible  merely  of  some  local  pains.  The  intellectual 
functions  had  not  been  impaired,  and  there  was  no  symptom 
of  compression  of  the  brain  or  of  paralysis  of  the  extremities; 
a  slight  traumatic  fever  supervened  on  the  third  day.  Mean- 
while, the  trephine  was  considered  as  the  only  means  from 
which  some  advantage  might  be  derived,  in  consequence  of 


Injuries  forbidding  the  Trephine.  175 

which  four  irregular  flaps  had  been  already  made  in  the  centre 
of  the  wound  and  a  part  of  the  cranium  rasped,  when  M.  Ribes 
and  myself  were  consulted.  On  account  of  the  little  intensity 
of  the  symptoms,  we  deemed  it  necessary  to  postpone  the  ope- 
ration, to  approximate  even  the  four  flaps,  and  after  washing  and 
cleansing  the  wound,  to  cover  it  with  some  fine  perforated 
linen,  steeped  in  hot  wine.  The  dressing  being  thus  accom- 
plished in  the  plainest  manner,  the  patient  was  directed  to 
have  lemonade  and  some  antispasmodic  draughts. 

The  pain  and  irritation  haying  subsided,  and  the  patient  har- 
ming undergone  so  marked  an  improvement,  the  operation  of 
trepanning  was  no  longer  thought  of.  Several  small  pieces  of 
bone  of  the  cranium  exfoliated  subsequently,  and  soon  after 
the  cure  was  completed.  The  cicatrix  was  large,  adhering,  and 
displayed  at  the  centre  a  pretty  considerable  loss  of  substance. 
The  cerebal  functions  had  not  been  impaired  in  the  least,  and 
this  officer  enjoyed  perfect  health  after  the  retreat  from  Russia. 

Third  Observation. — I  shall  now  conclude  the  account  of 
the  cases  bearing  upon  our  second  proposition,  by  relating  the 
following  fact,  the  details  of  which  have  been  communicated 
to  me,  during  the  campaign  in  Austria,  by  M.  Caizergues, 
surgeon  major's  mate,  at  the  same  time  when  he  sent  me 
the  scull  of  the  individual  who  was  the  subject  of  it. 

On  the  23d  March  1810,  a  private  of  the  61st  regiment  of 
infantry,  having  in  sport,  shot  at  Cristopher  Gros,  one  of  his 
comrades,  in  the  fullest  conviction  that  his  gun  was  not  loaded, 
the  latter  was  thrown  down,  and  had  his  head  from  the  middle 
of  the  forehead  to  the  left  side  of  the  nape  of  the  neck,  pierced 
through  entirely  by  a  large  piece  of  ramrod  which  had  been 
inadvertently  left  in  the  musket.  The  two  ends  of  this 
ramrod,  being  of  equal  thickness,  projected  externally 
to  the  cranium,  for  about  two  inches.  Notwithstanding 
this  severe  injury.  Gros  had  retained  sufficient  strength  to 
make  the  journey  from  the  spot,  where  he  had  been  wounded, 
to  the  ambulance,  (a  distance  of  one  league  and  a  quarter), 
partly  in  a  cart,  and  partly  on  foot.  There  was  no  hemorrhage 
from  the  nose  or  ears,  nor  had  any  of  the  functions  of  the 
life  of  relation  become  disordered  on  the  road. 


176  Injuries  forbidding  the  Trephine. 

After  several  trials  to  extract  this  foreign  substance  by  its 
anterior  extremity,  apiece  merely  of  about  five  inches  in  length 
had  been  pulled  out  with  tlie  pincers  used  for  that  purpose; 
and  from  the  broken  surface  it  appeared  that  what  is  called  a 
flaw  had  been  the  sole  cause  of  its  breaking  off.  Several  fur- 
ther attempts  to  draw  out  the  portion  remaining  within  the 
cranium  by  its  posterior  fragment,  had  proved  abortive,  and  it 
seemed  even  that  the  strongest  pincers  and  the  utmost  exer- 
tions had  been  made  towards  the  accomplishment  of  this  object, 
for  the  fragment  was  bent  and  marked  by  the  grip  of  the  in- 
struments. With  the  view,  at  length,  to  extricate  or  dislodge^ 
it  more  readily,  it  was  thought  best  to  apply  the  crown  of  a 
trephine  as  near  as  possible  over  the  spot  of  the  cranium  from 
whence  the  ramrod  protruded.  Contrary  to  all  the  principles 
of  surgery,  and  in  spite  of  the  danger  of  such  an  operation,  it 
was  performed  on  the  margin  of  the  occipital  foramen,  and 
within  a  few  lines  of  the  posterior  condyloid  foramen.  It 
must  have  been  necessary,  therefore,  to  divide  the  thick  layers 
of  the  trapezius,  splenius  and  complexus  muscles,  with  their 
blood  vessels  and  nerves,  iji  order  to  reach  the  bone.  M. 
Caizergues  has  said  nothing  of  the  difficulties  which  he  must 
necessarily  have  encountered,  nor  of  the  phenomena  which 
during  and  after  the  operation  must  have  arisen;  he  merely 
states  that  it  had  been  useless  and  that  he  had  been  obliged  to  give 
up  the  extraction  of  the  ramrod.  He  has  nevertheless  dropped 
the  remark  that  this  soldier,  who  expired  on  the  25th,  two  days 
after  the  accident,  had  borne  the  operation  with  the  utmost 
fortitude,  and  that  he  had  not  even  been  deprived  of  his 
senses. 

On  examination  after  death,  the  real  course  of  the  ramrod 
and  the  parts  injured  by  it  were  fully  ascertained.  The  os 
frontis  had  been  pierced  through  between  the  two  sinuses,  by 
making  an  opening  of  a  round  shape,  without  fracture,  and 
nearly  of  the  diameter  of  the  ramrod,  which  had  originally 
passed  in  an  horizontal  direction  between  the  two  hemispheres 
of  the  brain,  without  injury  to  either  of  them,  and  lacerated 
only  the  point  of  the  falx.  The  iron  afterwards  had  forced 
itself  into  the  substance  of  the  sphenoid  bone,  underneath  the 


Injuries  forbidding  the  Trephine.  \11 

left  optic  foramen;  it  had  then  pursued  its  career  through  the 
extremity  of  the  petrous  portion  into  the  cuneiform  process  of 
the  occipital,  by  making  an  inclination  towards  the  left  condy- 
loid apophysis  of  this  bone,  over  which  it  had  passed  at  its  base; 
and  finally  it  had  appeared  again  through  the  posterior  condy- 
loid foramen. 

Throughout  its  whole  career  the  ramrod  had  not  wounded 
one  important  organ.  It  had  not  touched  any  of  the  lobes  of 
the  hemispheres  of  the  brain;  but  had  glanced  under  the  caro- 
tid artery  and  the  cavernous  sinus,  without  injuring  either,  and 
even  was  found  separated  from  this  sinus  by  means  of  a  lamina 
of  bone  which  it  had  almost  detached  from  the  body  of  the 
sphenoid;  finally,  it  was  found  sufficiently  remote  from  the 
third  pair  of  nerves,  as  well  as  from  the  internal  jugular 
vein. 

The  resistance  ofiered  by  the  bones,  their  elasticity,  the 
breaking  of  the  projectile  power,  all  contributed  to  arrest  the 
march  of  the  foreign  substance  which  had  remained  wedged 
in  a  large  portion  of  the  bony  channel  through  which  it  had 
passed. 

The  inspection  of  the  cranium  of  this  man  naturally  sug- 
gests two  questions.  1.  What  might  have  become  of  him, 
if  he  had  been  left  to  the  sole  resources  of  nature,  bestowing, 
of  course,  such  attentions  on  him  as  his  condition  should  de- 
mand? His  death  seemed  unavoidable;  but  at  what  time  would 
it  have  overtaken  him?  We  are  unable  to  form  an  opinion, 
as  we  have  not  seen  the  patient,  and  as  we,  therefore,  do  not 
know  the  extent  to  which  his  organic  and  cerebral  functions 
had  been  involved.  The  investigation  of  this  point  seems  to 
have  been  totally  neglected.  If  we  consider,  however,  the 
absence  of  every  serious  symptom,  the  apparently  unimpaired 
integrity  of  the  functions  of  his  intellect,  of  his  senses  and  of 
the  powers  of  locomotion,  as  Cros  could,  after  the  accident, 
think  and  act  so  freely  that  he  travelled  on  foot  part  of  the  way, 
and  that  he  requested  to  allow  the  ramrod  to  remain,  support- 
ing his  request  by  stating  that  he  sufiered  but  little  pain  and 
uneasiness  from  it;  considering  all  these  circumstances,  we 
cannot  help  thinking  that  the  operation  ought  to  have  been  post- 
X 


178  Injuries  forbidding  the  Trephine. 

poned  to  such  a  period,  at  least,  as  when  it  would  have  seemed 
to  be  imperiously  required.  2.  On  the  other  hand,  what  advan- 
tage could  possibly  have  been  derived  from  it,  supposing  even 
that  it  could  have  been  performed  without  danger?  As  the 
measures  previously  employed  for  the  purpose  of  extracting 
the  ramrod,  such  as  the  use  of  pincers,  &c.,  had  proved  in- 
eflfectual,  so  the  trephine  could  add  nothing  to  the  efficacy  of 
the  former;  therefore  it  was  useless.  But,  independent  of  the 
difficulty  of  applying  it  in  the  most  deeply  seated  direction 
of  the  occipital  region,  may  it  not  have  been  injurious  also  to 
the  individual?  The  cerebellum,  or  at  all  events  the  dura 
mater,  must  have  been  wounded  by  the  teeth  of  the  trephine; 
for  the  part  of  the  trepanned  bone  exhibited  within  its  substance 
a  very  marked  difference  in  different  places  of  the  periphery 
of  the  opening,  and  it  is  well  known  that  lesions  of  the  cere- 
bellum are  extremely  dangerous.  Writers,  therefore,  have 
sufficient  reason  for  insisting  that,  in  the  application  of  the  tre- 
phine to  the  cranium,  the  circular  line  which  forms  the  demar- 
cation between  the  cap  and  the  base  of  the  cranium,  should  not  be 
overstepped.  In  this  case,  there  must  have  been,  consequently, 
less  danger  to  be  apprehended  from  its  presence  than  from  the 
disturbance  which  it  was  supposed  to  have  occasioned  in  the 
interior  of  the  cranium,  and  the  opening  of  the  body  has  prov- 
ed in  reality  that  it  might  have  remained  there  more  or  less 
long,  without  causing  the  death  of  the  individual,  as  there  was 
none  of  his  organs  injured.  This  example  justifies  the  apho- 
rism of  the  illustrious  father  of  medicine:  Experimentum 
jjericulosum,  judicium  difficile. 

The  result  of  our  observation  made  in  the  cabinet  of  natural 
history  of  thecity  of  Kœnigsberg,  in  Old  Prussia,  respecting  a 
wound  of  the  cranium  which  a  knight  of  the  Teutonic  order  had 
received,  seems  to  confirm  our  speculations  on  the  precedingfact. 
This  knight  had  been  wounded  on  the  forehead,  by  a  javelin, 
the  point  of  which  had  broken  off  in  the  cranium,  and  re- 
mained there  for  the  space  of  fourteen  years,  without  inter- 
fering with  his  occupation.  Subsequently  to  this  period,  a 
collection  of  matter  was  formed  at  the  base  of  the  frontal  re- 
gion, in  which  the  point  of  the  weapon  was  observable;  its  ex- 


TVeatment  of  Hernia  Cerebri.  179 

traction  had  been  made  without  difficulty,  and  resulted  in  the 
recovery  of  the  individual. 

Third  Proposition,  concerning  the  mode  of  treatment  in 
■cases  of  hernia  cerebri. 

Before  I  venture  upon  the  consideration  of  this  proposition, 
a  question,  highly  important,  yet  difficult  to  answer,  naturally 
presents  itself:  what  is  the  cause  capable  of  producing  hernia 
cerebri  through  an  opening  which  has  been  made  into  the  cra- 
nium, either  by  some  offisnding  substance,  or  by  the  operation  of 
the  trephine?  Without  presuming  to  give  a  perfect  solution, 
I  shall,  nevertheless,  endeavour  to  present  it  in  such  a  light  as 
may  lead  to  the  path  of  truth. 

According  to  our  experience  in  a  great  many  cases,  the  irri- 
tation which  is  centred  in  that  part  of  the  brain  corresponding 
to  the  opening  into  the  cranium,  may  depend  as  much  upon 
its  contact  wth   the  external  air,  as  on  the  presence  of  any 
foreign  substances.     The  encephalon,  traversed  as  it  is  in  the 
literal  meaning  of  the  expression  by  innumerable  fasciculi  of 
arterial  ramifications,  must  undergo  a  spontaneous  movement 
of  expansion,  the  effects  of  which  will  be  the  more  perceptible 
as  the  parietes  of  the  cranium  no  longer  present  an  equal  re- 
sistance at  all  points  of  its  cavity.      Thus,  if  a  single  portion 
of  this  bony  wall   be  wanting,  the  corresponding  part  of  the 
brain,  being  now  no  longer  opposed  by  it,  yields  to  the  impulse 
and  to  the  dilation  of  its  proper  vessels;  this  part  then   begins 
to  swell,  escapes  through  the  opening,  and  immediately  occa- 
sions the  hernia.     By  degrees  this  fresh  growth  increases,  and 
forms  outside  the  cranium  a  tumour  of  more  or  less  volume, 
in  which  certain  phenomena  of  vital  expansion,  not  to  be  ob- 
served in  health,  become  subsequently  developed.     Any  press- 
ure exerted  upon  these  cerebral  excrescences  occasions  a  sen- 
sation of  weight  throughout  the  whole  extent  of  the  wound; 
and  if  the  pressure  be  continued,  the  patient  will  experience 
nausea  and  pandiculations;  the  functions  of  sensation  are  dis- 
turbed, and  syncope  supervenes. 

If  the  tumour  be  cut  off,  the  divided  extremity  will  form  a  new 
growth,  which,  if  cut  again,  will  be  alike  reproduced.  In  other 
respects  such  excisions  cannot  be  made  without  their  being 


180  Treatment  of  Hernia  Cerebri. 

productive  of  very  serious  mischief,  followed  by  death.  We 
witnessed  an  example  of  this  in  the  Saxon  army,  1813. 
Whilst  visiting  the  hospital  of  the  arsenal  at  Dresden,  I  saw 
one  of  our  wounded  soldiers  who  had  just  been  dressed,  die  a 
few  minutes  afterwards,  in  the  most  dreadful  convulsions. 
We  learned,  and  the  removal  of  the  dressing  confirmed  it,  that 
agreeably  to  the  rules  laid  down  by  authors,  the  surgeon  had 
deemed  it  necessary  to  cut  off  a  pretty  considerable  portion  of 
brain  which  constituted  the  hernia  through  an  opening  of  about 
half  an  inch  in  diameter,  occasioned  by  the  extraction  of  a 
splinter.  During  the  operation  itself,  there  occurred  nothing 
but  a  slight  syncope,  preceded  by  disposition  to  vomit  and  by 
frequent  gasping. 

Writers  have  also  recommended  to  compress  these  tumours, 
and  some  have  proposed  to  make  use  of  plates  of  lead  for 
this  purpose.  Such  a  method,  as  well  as  the  application  of 
alcoholic  and  astringent  lotions  may  bring  on  fits,  by  increas- 
ing the  irritation,  and  by  disturbing  the  exercise  of  the  vital 
properties  of  that  portion  of  the  brain  with  which  they  come 
in  contact. 

What,  therefore,  should  a  surgeon  do  in  a  case  of  encepha- 
locele  occasioned  by  some  accidental  loss  of  the  substance  of  the 
bones  of  the  cranium? 

It  is,  first  of  all,  proper  to  observe,  that  an  extensive  hernia 
of  the  brain  is  one  of  the  most  formidable  occurrences  incidental 
to  injuries  of  the  head,  and  that  it  is  a  very  rare  circumstance 
if  they  who  have  become  subject  to  it  survive.  The  develop- 
ment of  these  herniae  presupposes  an  exceedingly  exalted 
state  of  the  irritability  of  the  pia  mater  and  the  cerebral  blood 
vessels,  as  well  as  a  deep  seated  inflammation  within  the  paren- 
chymatous substance  of  the  brain  itself,  which  it  is  difficult, 
if  not  impossible,  altogether  to  cure.  Again,  the  usual  means 
which  have  been  devised  for  the  purpose  of  repressing  them, 
so  far  from  causing  them  to  return,  are  instrumental  only  in 
the  development  of  the  causes  of  these  exuberances.  We  have 
seen  all  the  individuals  perish  to  whom  these  remedies  were 
applied;  only  one,  in  whom  the  hernia  was  not  so  voluminous, 
while  the  treatment  was  conducted  in  the  simple  manner  of 
which  we  intend  to  speak,  escaped   indeed  the  symptoms  de- 


^abscesses  of  the  Liver  after  Injuries  of  the  Head.    181 

scribed  above;  the  tumour  gradually  returned,  and  the  patient 
recovered. 

This  treatment  consists  in  applying  over  the  protruded  cere- 
bral substance,  a  fine  and  perforated  piece  of  linen,  soaked 
in  oil  of  chamomile  slightly  camphorated,  and  in  directing  our 
principal  attention  to  the  removal  of  the  cause  of  internal  ex- 
citement, and  of  the  mechanical  irritation  externally.  With 
this  object  in  view,  it  is  necessary  to  extract  with  proper  care 
every  extraneous  body,  as  far  as  it  is  practicable  to  preserve  the 
injured  parts  from  coming  in  contact  with  theexternal  air,  to  pre- 
scribe an  antiphlogistic  diet,  and  finally  to  apply  the  dressings 
with  the  utmost  gentleness,  and  in  such  a  manner  that  the  appa- 
ratus shall  not  make  any  kind  of  pressure  upon  the  sensitive  parts. 
Ifthe  hernia  is  susceptibleof  being  reduced,  nature,  thus  assisted, 
Avill  accomplish  it  by  degrees,  and  the  protruded  portion  of 
brain  will  return  entirely  into  the  cranium,  like  the  epiploon, 
when  it  has  escaped  through  a  wound  of  the  abdomen. 

Fourth  Proposition,  being  an  investigation  of  the  causes 
of  abscesses  of  the  liver,  subsequently  to  injuries  of  the  head. 

A  great  many  hypotheses  have  been  advanced  one  after 
another,  in  order  to  explain  the  causes  of  abscesses  of  the  liver 
subsequently  to  injuries  of  the  head,  as  well  as  the  sympathetic 
relations  supposed  to  exist  between  the  brain  and  liver;  and 
they  have  been  more  or  less  countenanced,  in  proportion  to 
the  period  and  celebrity  of  their  authors.  I  shall  not  attempt 
to  inquire  again  into  those  which  have  already  been  the  object 
of  the  debates  of  the  former  academy  of  surgery  and  of  authors; 
I  shall  limit  my  observations  simply  to  the  opinion  which  in 
our  days  appears  to  be  most  generally  adopted. 

The  celebrated  author  with  whom  it  has  originated,  refers 
the  causes  of  the  formation  of  these  abscesses  to  the  direct  or 
indirect  concussion  sustained  by  the  liver,  at  the  same  moment 
when  the  offending  cause  has  produced  the  injuries  of  the 
head.  In  support  of  this  opinion,  the  author  says:  ''  that 
those  wounds  which  are  occasioned  by  the  immediate  shock 
of  the  cranium,  in  which  the  concussion  is  confined  to  the 
brain,  and  does  not  extend  to  the  other  viscera,  are  never 


182  Abscesses  of  the  Liver  after  Injuries  of  the  Head. 

complicated  by  abscesses  of  the  liver,  an  evident  proof  that 
the  connexion  existing  between  the  diseases  of  the.  liver 
and  brain  should  be  ascribed  to  the  simultaneous  shock  sus- 
tained by  these  two  organs."  (Nosographie  Chir.,  4e  edition, 
1815.)  This  explanation  is  accompanied  by  a  number  of 
cases  and  experiments  made  on  forty  dead  subjects. 
We  shall  confine  ourselves  to  the  following  remarks: 
1.  The  cases  which  the  author  produces,  do  not  appear  to 
us  to  stand  in  an  exact  relation  throughout  with  the  injuries  of 
the  cranium,  at  least  not  in  the  sense  of  the  actual  question 
before  us.  The  subjects  of  the  two  first  died  twelve  or  fifteen 
hours  after  the  accident,  and  it  so  happened,  during  the  vio- 
lent fall  which  they  had  had  from  some  very  elevated  place, 
that  the  bodies  of  these  persons  having  been  accidentally 
thrown  upon  the  right  hypochondrium,  the  liver,  friable  and 
dense  as  it  is,  had  sustained  such  a  shock  that  it  must  necessa- 
rily break  and  become  lacerated  to  a  greater  or  lesser  extent, 
while  the  integuments  of  the  thorax  and  abdomen  might  have 
escaped  unhurt.  This  phenomenon  resembles  that  which  a 
musket  ball,  at  the  termination  of  its  career,  produces  upon 
the  soft  and  rounded  parts  which  it  strikes;  and  the  same  will 
apply  to  the  wheel  of  any  vehicle  which  should  pass  over  the 
same  parts;  therefore,  these  derangements  of  the  liver  may 
occur,  in  the  instance  of  the  fall  of  individuals,  without 
there  being  the  slightest  injury  of  the  cranium  or  the  brain. 
We  have  witnessed  this  repeatedly,  and  the  injury  either  of 
the  liver  or  the  encephalon,  though  occasioned  by  analo- 
gous causes,  may  very  well  exist  separately.  Of  this  there  is 
here  an  example.  A  domestic  was  brought  to  the  military 
hospital  of  Gros  Caillou,  on  the  13th  February  1817,  on  account 
of  a  severe  fall  which  he  had  had  from  his  horse,  in  the  trenches 
of  the  Champ-de-Mars.  The  weight  of  the  body  chiefly  rested 
on  the  right  hypochondrium.  He  died  a  few  hours  after  ad- 
mittance into  the  hospital.  On  opening  the  body,  which  we 
did  two  days  afterwards,  we  found  the  integuments  of  the 
whole  body  sound,  the  abdomen  tympanitic,  the  right  hypo- 
chondrium much  more  elevated  than  the  left;  about  two  pounds 
of  black  and  bilious  blood  had  been  effused  in  the  cavity  of  the 


.abscesses  of  the  Liver  after  Injuries  of  the  Head.    183 

abdomen;  all  the  floating  viscera  of  this  cavity  were  inflamed; 
two  rents  were  observed  on  the  concave  surface  of  the  liver, 
the  volume  of  which  was  reduced,  and  the  texture  of  the  cor- 
responding sides,  being  softened,  crumbled  at  the  least  efibrt; 
the  intercostal  muscles  and  the  right  side  of  the  diaphragm 
were  ecchymosed.  It  is  evident  that  the  cause  of  this  almost 
sudden  death  must  be  attributed  to  the  laceration  of  the  liver, 
an  event  which  invariably  proves  fatal,  if  it  communicates 
with  the  peritoneal  cavity. 

2.  The  experiments  made  upon  dead  bodiesare,  in  our  opinion, 
not  better  calculated  to  solve  the  problem  in  question.  First  of 
all,  with  what  show  of  reason  can  the  causes  of  certain  pheno- 
mena, observed  in  inanimate  subjects,  be  applied  to  the  living 
bodies?  and  what  shall  we  think,  in  the  next  place,  of  the  con- 
currence of  the  causes  which  simultaneously  change  the  struc- 
ture of  the  liver  and  brain,  while  in  many  instances,  on  the 
occasion  of  violent  falls,  which  were  sooner  or  later  followed 
by  the  death  of  the  individuals  who  had  sustained  them,  we 
found  on  dissection,  the  cranium  and  the  extremities  fractured, 
whilst  the  liver  had  remained  unchanged?  We  shall  give  a 
brief  account  of  three  cases  which  will  prove,  I  trust,  in  oppo- 
sition to  the  opinion  held  by  the  advocates  of  the  theory  of 
mechanical  causes  of  abscesses  of  the  liver,  that  if  is  exceed- 
ingly difficult  for  this  organ  to  become  disorganised  from  a  fall 
or  concussion,  especially  if  the  weight  of  the  body  should  not 
directly  and  powerfully  bear  upon  it;  and  then  this  latter  cir- 
cumstance is  of  such  rare  occurrence  that  I  have  met  with  but 
one  instance. 

Fi7'st  Observation. — A  young  chasseur  of  the  ex-guards,  a 
patient  of  the  hospital  of  Gros  Caillou,  in  a  fit  of  delirium, 
jumped  from  a  window  of  the  second  floor,  and  fell  upon  the 
pavement  in  the  yard:  he  was  instantly  cari'ied  into  the  ward 
of  the  wounded,  where,  a  few  hours  afterv/ards,  he  expired. 
We  carefully  opened  his  body  in  order  to  observe  the  derange- 
ment which  we  believed  to  exist  in  the  liver.  We  noticed, 
1st,  a  well  marked  diastasis  of  the  parietal  bones,  between 
themselves  and  between  the  os  frontis:  2dly,  at  the  occipital 
bone,  which  had  not  been  at  all  displaced,  there  was  a  fracture 


184   tâbscesses  of  the  Liver  after  L} juries  of  the  Head. 

with  splinters,  the  rays  of  which  extended  and  diverged  to- 
wards the  base  of  the  cranium;  the  dura  mater  was  in  sev- 
eral places  detached  from  the  roof  of  the  cranium,  the  brain 
was  sunk  down  and  gorged  with  blood,  and  the  ventricles 
were  filled  with  a  large  quantity  of  the  same  fluid:  3dly,  there 
was  a  luxation  of  the  right  arm,  combined  with  shattering  of 
the  elbow  of  the  same  side;  the  left  thigh  bone  was  broken, 
and  the  sixth  and  seventh  vertebrae  were  fractured. 

On  opening  the  abdomen  we  were  astonished  to  find  the  liver 
and  othervisceraunchanged  ;  the  intestines  were  merely  distend- 
ed with  gas.  A  small  quantity  of  blood  had  been  effused  into 
the  right  cavity  of  the  thorax,  which  arose  from  the  vena  azy- 
gos  having  been  ruptured.  The  lungs  and  the  heart  exhibited 
nothing  remarkable. 

Second  Observation. — Peter  Gérard,  superintendent  of  the 
kitchen  of  the  hospital  of  Gros  Caillou,  returned  home  in  a 
state  of  intoxication,  in  the  night  of  the  4th  to  the  5th  Sep- 
tember 1815.  Being  very  warm,  he  seated  himself  upon  the 
window-frame  of  his  chamber,  with  the  back  turned  towards 
the  yard.  In  this  position  he  fell  asleep,  and  inclining  in- 
voluntarily backwards,  he  tumbled  head  over  heels  out  of  the 
window.  Upon  the  noise  of  his  fall,  people  came  to  his  assist- 
ance, and  found  him  stretched  out  in  a  state  of  perfect  immo- 
bility, and  almost  deprived  of  life. 

The  two  lower  extremities  were  shattered,  and  the  right,  in 
particular,  was  entirely  disorganized.  A  superficial  and  con- 
tused wound  was,  moreover,  observed  on  the  right  temple, 
without  fracture  of  the  cranium,  besides  which  there  were 
several  violent  contusions  on  different  parts  of  the  body.  Not- 
withstanding the  extreme  exhaustion  of  the  patient,  occasioned 
by  a  profuse  hemorrhage  from  the  anterior  tibial  artery,  we 
deemed  it  indispensable  to  fulfil  the  urgent  indication  of  am- 
putating the  disorganized  leg.  We  performed  this  operation 
close  to  the  knee  through  the  substance  of  the  head  of  the 
tibia.  The  other  leg,  though  it  had  been  shattered  likewise, 
yet  countenanced  some  hope  of  its  being  preserved,  and  was 
put  accordingly  into   a   suitable  apparatus.       Embrocations 


abscesses  of  the  Liver  after  Injuries  of  the  Head.    185 

with  hot  and  camphorated  brandy  were  applied  over  the  en- 
tire surface  of  the  body  and  a  rigid  diet  was  prescribed. 

The  first  three  or  four  days  were  passed  in  a  state  of  great 
perturbation;  but,  after  the  seventh,  these  alarming  symptoms 
subsided,  which,  by  defeating  our  measures,  had  till  then  depri- 
ved us  of  the  hope  of  preserving  the  life  of  the  patient.   The  sup- 
puration of  the  stump  being  established,  had  become  copious, 
and  in  a  few  days  more  the  wound  was  cleansed.     A  traumatic 
fever  broke  out  and  might  have  been  regarded  as  a  favourable 
symptom;  the  patient  improved  visibly,  and  he  was  in  a  situa- 
tion the  most  auspicious  for  his  recovery,  when,  in  the  night  of 
the  17th  September  he  was  overtaken  by  death,  after  having 
conversed  for  a  considerable  time  with  the  nurse  of  the  ward. 
During  the  whole  time  of  his  illness,  he  had  continually  suffered 
from  pain  in  the  epigastrium,  attended  by  a  sensation  of  heavi- 
ness and  weakness.     We  had  scarified  cups  and  blisters  applied 
over  this  region. 

On  inspecting  the  body  after  death,  we  found  the  abdomen 
tense  and  meteorised;  the  stomach  and  the  intestines  were  dis- 
colored and  distended  with  gas;  the  mucous  membrane  of  the 
stomach  displayed  in  various  places  of  its  surface  the  signs  of 
a  phlogose  condition.  The  liver  and  the  other  viscera  of  the 
abdomen  were  in  their  natural  state;  the  lungs  presented  no- 
thing particular.  The  ventricles  of  the  heart  contained  some 
albuminous  concretions  of  a  yellowish  aspect.  The  arterial 
system  was  filled  with  gas,  and  the  veins  contained  very  little 
black  and  coagulated  blood.  The  blood  vessels  of  the  brain 
were  slightly  engorged.  Upon  this  organ,  at  the  spot  which 
corresponded  with  the  contusion  of  the  temple,  there  was  an 
ecchymosis  which  extended  over  a  large  portion  of  the  middle 
lobe  of  the  hemisphere. 

The  causes  of  death  may  in  reality  be  referred  to  the  con- 
cussion of  the  brain,  to  the  almost  sudden  atony  of  the  intes- 
tines, to  the  sinking  of  the  nervous  system,  and  to  the  hemorr- 
hage which  took  place  immediately  after  the  fall. 

Third  Observation. — This  case,  even  more  than  the  preced- 
ing, will  confirm  the  views  which  we  have  suggested  in  order 
Y 


186    Abscesses  of  the  Liver  after  Injuries  of  the  Head. 

to  prove  that  abscesses  of  the  liver,  of  which  we  speak  at  pre- 
sent, are  by  no  means  the  consequences  of  mechanical  causes. 

Frederic  Habrer,  a  soldier  of  the  train  of  the  fourth  regiment 
of  cuirassiers  of  the  guards,  aged  34,  of  a  robust  constitution, 
had  been  engaged  upon  a  cart  loaded  with  hay,  in  tightening 
the  rope  which  was  to  press  down  and  keep  this  quantity  of 
forage  together,  when  he  was  suddenly  lifted  up  by  an  unex- 
pected jerk  of  the  rope,  after  it  had  become  unhooked  from  the 
beam,  the  cross  piece  of  which  had  slipped  out  of  the  hands  of 
his  assistant:  having  been  tossed  at  first  several  feet  above  the 
pile  of  hay,  he  was  next  thrown  upon  the  pavement  of  the 
street,  where  he  remained  for  a  few  moments  without  exhibit- 
ing the  slightest  signs  of  life.  He  was  lying  on  the  right  side, 
bathed  in  blood,  urine  and  stercoraceous  matter,  the  result  of 
the  hemorrhage  from  the  nose  and  ears,  as  well  as  of  the  pre- 
cipitate and  involuntary  discharge  of  urine  and  feculent  matter. 

On  his  arrival  at  the  hospital  of  Gros  Caillou,  October  5th, 
1816,  at  7  o'clock,  A.M.,  he  was  pale,  disfigured,  drowsy  and 
in  a  sinking  and  generally  paralytic  state;  the  whole  right  side 
of  the  face  was  ecchymosed  and  the  cheek  considerably  swollen; 
his  nose  was  driven  in,  and  there  was  a  transverse  wound  above 
the  right  eye-brow,  combined  with  a  radiated  fracture  of  the 
frontal  bone,  prodigious  swelling  of  the  eye-lids  and  total  oc- 
clusion of  the  eye;  the  shoulder,  the  arm,  the  elbow,  the  back, 
and  particularly  the  haunch  of  the  same  side,  were  ecchymosed 
and  excoriated.  At  times  he  was  out  of  his  senses,  and  trem- 
bled in  every  limb;  he  had  scarcely  any  pulse,  and  to  the 
questions  put  to  him  he  could  make  no  answer;  in  short,  I  be- 
lieved him  to  be  in  the  utmost  danger.  Warmth  of  the  body 
being  restored,  his  head  was  shaved  and  covered  with  com- 
presses, soaked  in  very  hot  and  camphorated  vinegar.  I  or- 
dered sinapisms  to  the  feet  and  prescribed  an  antispasmodic 
draught  for  the  night. 

Symptoms  of  inflammation  of  the  injured  parts  and  of  the 
cerebral  membranes  having  supervened  on  the  nextday,  I  freely 
dilated  the  wound  and  exposed  the  fracture,  which,  like  the 
fragment  of  a  star,  divided  the  external  wall  of  the  right  frontal 
sinus.     Some  nervous  branches  which  had  been  lacerated  by 


JÎbscesses  of  the  Liver  after  Injuries  of  the  Head.     187 

the  offending  cause,  were  included  in  my  incisions,  without 
any  untoward  symptoms  resulting  from  it;  but,  I  studiously 
abstained  from  rasping  the  bone,  as  is  recommended  by  authors 
for  the  removal  of  the  pericranium,  seeing  beforehand  that  the 
trephine  would  not  be  necessary,  as  no  bony  fragments  were 
sunk  inwards.  The  wound  was  simply  dressed,  and  the  pa- 
tient put  upon  the  use  of  diluents,  purgative  enemata  and  em- 
brocations of  camphorated  brandy  over  all  the  ecchymosed 
parts.  It  became  necessary  for  several  days  unrelentingly  to 
persevere  with  the  most  powerful  antiphlogistic  measures,  in 
order  to  appease  the  pain  and  inflammation  which  returned  upon 
the  slightest  causes. 

The  system  was  tranquillized  at  last,  and  the  patient,  who, 
until  the  eighth  day  had  vegetated  in  a  state  of  stupor  and  non- 
entity of  his  sensitive  functions,  resumed  the  use  of  them  and 
asked  himself  for  every  thing  he  stood  in  need  of.  Suppura- 
tion became  established  and  abundant;  several  small  abscesses, 
having  been  formed  successively  in  the  substance  of  the  eye- 
lids of  the  right  eye  and  at  the  root  of  the  nose,  were  opened. 
On  the  thirteenth  day,  the  patient  was  in  the  most  satisfactory 
condition,  when  all  at  once  symptoms  of  adynamia  made  their 
appearance,  accompanied  by  stupor  and  a  well  marked  gastric 
derangement.  Suppuration  had  not  been  at  all  diminished, 
but  it  bore  a  greyish  aspect,  and  the  wound  presented  an  ugly 
appearance.  I  hastened  to  give  him  an  emetic,  composed  of 
25  grains  of  ipecacuanha  and  one  grain  of  tartarized  antimony: 
this  produced  copious  evacuations,  both  upwards  and  down- 
wards, succeeded  by  abundant  perspiration  and  perfect  tran- 
quillity. The  patient,  however,  remained  still  in  a  state  of 
almost  habitual  somnolency,  and  complained  always  of  pain  in 
the  head.  As  there  existed  no  other  symptom  of  paralysis  in 
the  extremities,  or  of  effusion  beneath  the  cranium,  I  refused 
to  apply  the  trephine,  however  much  the  physicians  who 
had  seen  the  patient  believed  it  to  have  been  indicated.  I  di- 
rected the  region  of  the  head,  where  the  wound  was  situated,  to 
be  covered  by  a  large  blister,  and  prescribed  for  the  next  day  a 
decoction  of  calisaya  bark.  Broths,  good  wine  and  the  aro- 
matic embrocations  were  continued.     AH  the  symptoms  dis- 


188    ^abscesses  of  the  Liver  after  Injuries  of  the  Head. 

persed  rapidly,  the  patient  continued  improving,  the  functions 
of  his  senses  and  organs  were  restored;  several  small  fragments 
of  bone,  belonging  to  the  nose  and  external  wall  of  the  frontal 
sinus  exfoliated;  the  wounds  cicatrized;  the  sight  of  the  right 
eye  had  not  been  impaired;  and  he  was  altogether  in  a  proper 
condition  to  leave  thé  hospital  in  the  early  part  of  December 
of  the  same  year.  This  fact  is  another  proof  that  the  trephine 
is  not  necessary,  except  in  those  cases  which  we  have  pointed 
out. 

If,  as  has  been  alleged,  the  liver,  in  consequence  of  a 
violent  fall,  were  susceptible  of  being  lacerated  or  changed 
so  as  to  produce  inflammation  or  immense  abscesses,  the  in- 
dividuals who  were  the  subjects  of  the  preceding  observations, 
ought  to  have  exhibited  these  changes  of  structure  in  the  high- 
est degree;  and  yet  we  meet  with  them  frequently  superven- 
ing on  trifling  injuries  of  the  head  without  fracture,  and  with- 
out the  patient's  having  sustained  a  fall  or  concussion  violent 
enough  to  react  upon  the  hepatic  system. 

The  weight,  the  organisation  of  this  viscus  and  the  situation 
it  occupies  in  the  abdominal  cavity,  have  been  ingeniously 
called  into  aid  to  support  the  hypothesis  of  structural  changes 
so  gratuitously  ascribed  to  it;  nature,  in  this  respect,  has  been 
charged  with  neglect;  but  as  regards  this  and  every  other  organ 
of  the  animal  economy,  she  has,  on  the  contrary,  so  well 
arranged  her  measures  and  precautions,  that  save  by  any  direct 
and  truly  destructive  agency,  the  liver  no  more  than  any  other 
viscus  is  susceptible  of  being  detached,  of  breaking  or  becoming 
changed  by  the  operation  of  a  fall  or  any  other  indirect  shock. 
Whatever  may  be  in  other  respects  the  condition  of  the 
stomach,  yet  it  would  never  involve  the  loss  of  the  equilibrium 
of  the  individual,  and  it  would  be  easy  to  prove  the  truth  of 
this  assertion,  if  daily  experience  did  not  dispense  us  so  to  do. 
I  have  made  some  analogous  observations  at  the  instance  of 
the  spontaneous  rupture  of  arteries,  to  which  it  has  been  sug- 
gested to  refer  the  essential  cause  of  aneurisms,  of  such  even  as 
are  situated  internally. 

But  it  is  time  that  we  ourselves  should  endeavour  to  solve 
the  problem  under  discussion,  and  to  point  out  the  causes  of 


Abscesses  of  the  Liver  after  Injuries  of  the  Head.    189 

the  formation  of  abscesses  of  the  liver  subsequently  to  injuries 
of  the  head.  Some  recent  writers.  Dcsault  in  particular,  have 
vaguely  hinted  these  causesj  without  developing  them. 

We  have  had  occasion  for  some  time  past  to  observe  that 
the  functions  of  the  pulmonary  and  biliary  apparatus  were  dis- 
turbed and  sensibly  acted  upon  by  the  phlegmasias  of  the 
fibrous  membranes  of  the  head  or  extremities,  especially  of 
those  which  correspond  with  the  organs  situated  alongside  of 
them.  It  would  appear  that  any  irritation  set  up  in  some  por- 
tion of  the  fibrous  membranes  spreads  rapidly  and  sympatheti- 
cally towards  the  centre  of  the  viscera  which  receive  their  sti- 
mulus from  the  nerves  of  function;  the  liver,  as  the  most  com- 
plicated organ,  where  the  capillary  circulation  is  the  least  active, 
and  where  the  fibrillae  of  the  intercostal  nerve  are  more  nume- 
rous, appears  to  be  pre-eminently  susceptible  of  the  effects  of 
this  sympathetic  irritation.  The  vital  properties  are  soon  dis- 
ordered; inflammation  becomes  established  with  more  or  less 
promptness  and  intensity;  an  abscess  is  formed  and  travels 
through  itsdifferentstages.  These  abscesses,  when  once  formed, 
contribute  doubtless  towards  the  death  of  the  patient,  and  would 
in  themselves  be  capable  of  destroying  him  sooner  or  later, 
even  if  he  should  resist  the  consequences  of  the  primary  or 
traumatic  inflammation.  But  it  is  by  no  means  so  uniformly 
after  injuries  of  the  head  that  these  derangements  of  the  hepatic 
system  are  more  particularly  observed;  for,  we  have  also  seen 
many  persons  with  injuries  of  the  ginglymoid  articulations  of 
the  upper  or  lower  extremities  perish  of  abscesses  of  the  liver 
which  had  been  developed  probably  since  the  injury  of  the 
parts  affected.  This  organ,  moreover,  is  not  the  only  viscus 
liable  to  be  attacked  at  the  instance  of  injuries  of  the  head  or 
of  other  parts  of  the  body;  by  virtue  of  the  reasons  which  we 
have  assigned  above,  every  other  organ,  be  it  of  the  chest  or 
of  the  abdomen,  is  subject  to  the  irritation  arising  from  the  in- 
jury, and  may  separately  present  derangements  analogous  to  it. 

It  is  possible  also  that  the  fluids,  which,  being  more  or  less  hete- 
rogeneous in  their  character,  exude  from  the  wound,  may  be 
transmitted  to  the  liver  by  the  cellular  tissue,  particularly  if  the 
wounds  should  be  irritated  by  too  frequent  and  careless  dress- 


190     Mscesses  of  the  Liver  after  Injuries  of  the  Head. 

ings,  and  if  the  sudden  suppression  of  the  cutaneous  perspira- 
tion, that  of  the  alvine  discharges  and  a  morbid  susceptibility  of 
the  hepatic  system  should  become  associated  with  the  traumatic 
causes  just  enumerated.  We  shall  now  proceed  to  relate  some 
cases  which  doubtless  will  be  sufiBcient  to  settle  the  opinion  of 
practitioners  on  tlie  subject. 

First  Observation. — One  of  the  Prussian  soldiers  of  whom 
we  had  charge  at  the  hospital  of  Gros  Caillou,  during  the 
month  of  June  1814,  had,  ever  since  the  battle  of  Paris,  two 
fistulous  sores  at  the  middle  of  the  right  arm,  combined  with  loss 
of  substance  of  the  humerus  and  a  false  articulation.  The  two 
fragments  appeared  to  have  been  rounded  off  at  their  articu- 
lating surfaces,  so  as  to  ride  with  facility  upon  each  other;  the 
limb,  in  other  respects,  was  sound  and  the  subject  himself  in 
pretty  good  condition.  In  order  to  accomplish  the  re-union 
of  the  fragments,  the  seton  has  been  applied  to  this  false  articu- 
lation, a  remedy  which  has  been  devised  by  the  English,* 
and  recommended  by  some  French  physicians.  (Seethe  "Dis- 
sertation de  M.  le  docteur  Laroche,  No.  428,  in  4to.").  A  strip 
of  fringed  lint  had  been  in  consequence  passed,  with  the  aid 
of  a  seton  needle,  betwixt  the  two  bony  fragments. 

Symptoms  of  inflammation  exhibited  themselves  before  the 
expiration  of  the  fifth  day,  and  were  rapidly  developed.  The 
two  bony  extremities  and  the  surrounding  soft  parts  swelled 
to  such  a  degree  that  the  engorgement  spread  as  far  as  the 
shoulder  and  fingers.  To  these  local  symptoms  were  super- 
added violent  pains  in  the  right  hypochondrium,  difficulty  of 
respiration,  oppression,  and  a  high  traumatic  fever.  Seeing 
the  patient  in  this  condition,  the  first  thing  we  did  was  to 
withdraw  the  seton,  and  to  direct  the  application  of  emollients 
to  the  affected  limb  and  of  two  scarified  cups  to  the  hypochon- 


*  The  claims  of  the  venerable  Coryphceus  of  American  surgery,  Dr  Physick  of 
Philadelphia,  to  the  originality  and  ingenuity  of  the  application  of  the  seton 
needle  in  cases  of  disunited  fractures  of  long  standing,  are  so  fully  admitted  at 
home  and  abroad,  that  the  bare  mentioning  of  the  fact  would  be  an  act  of  supere- 
rogation, were  it  not  for  the  vagueness  of  the  term  "  English"  used  in  the  origi- 
nal text,  so  as  to  merge  American  merit  in  the  general  vortex  of  the  English 
practice.     Suiim  cuiqueJ — Trans. 


jîbscesses  of  the  Liver  after  Injuries  of  the  Head.    191 

drium,  and  afterwards  to  prescribe  refrigerants  and  antispas- 
modics; but  these  measures  were  useless;  the  symptoms  increa- 
sed, gangrene  made  its  appearance  in  both  wounds  of  the  arm 
which  had  attained  an  enormous  size,  while  the  patient  felt  at 
the  same  time  lancinating  pains  in  the  region  of  the  liver.  A 
few  days  later,  we  perceived  on  the  edge  of  the  false  ribs  a 
protruding  and  fluctuating  tumour,  presenting  all  the  symptoms 
of  an  abscess  of  the  liver.  His  feeble  and  wasted  frame  would 
not  permit  us  to  employ  any  of  the  remedies  which  were  indi- 
cated for  the  disease  of  the  arm  and  liver;  he  died  in  fact 
twenty -four  hours  afterwards. 

On  dissecting  the  arm  the  next  day,  we  discovered  a  deep 
seated  and  extensive  inflammation  of  the  membranes  of  the 
bony  fragments  on  which  it  had  settled.  Sinuses  extended  as 
far  as  the  arm-pit  and  under  the  pectoral  muscles.  There  was 
an  enormous  abscess  within  the  substance  and  in  the  centre  of 
the  large  lobe  of  liver,  almost  ready  to  burst  into  the  cavity  of 
the  abdomen. 

It  is  very  certain  that  these  abscesses  were  the  results  of  the 
irritation  and  inflammation  of  the  arm,  because,  until  then  the 
patient  had  not  complained  of  any  indisposition  which  could 
have  induced  us  to  suspect  the  slightest  structural  change  of 
the  liver. 

(The  three  next  observations  refer  to  three  soldiers  of  the 
ex-guards  who,  in  1811,  were  in  succession  brought  to  the 
hospital  of  Gros  Caillou  on  account  of  sabre  wounds  which 
they  had  received  in  duels.) 

Second  Observation. — In  the  case  of  a  young  chasseur,  a 
sabre  cut  had,  besides  the  integuments,  carried  away  a  piece 
of  bone,  of  an  oval  shape  and  about  one  inch  and  a  half  in  length, 
belonging  to  the  external  table  and  diploë  of  the  middle  por- 
tion of  the  right  parietal  bone.  The  injury  had  been  treated 
as  a  simple  incised  wound  and  covered  merely  by  a  fold  of 
linen,  soaked  in  hot  and  honeyed  wine,  and  kept  in  its  place  by 
compresses  and  a  suitable  bandage.  The  patient  was  restricted 
to  a  cooling  regimen.  The  ten  first  days  were  passed  with- 
out any  unpleasant  symptom;  on  the  eleventh,  the  suppuration 
dried  up  and  the  edges  of  the  wound  turned  red  and  inflamed;  he 


1 92    tâbscesses  of  the  Liver  after  Injuries  of  the  Head. 

had  fever,  combined  with  cephalalgia,  tinkling  of  the  ears, 
delirium,  burning  thirst,  deep  seated  pain  and  oppression  in 
the  right  hypochondrium.  We  directed  leeches  to  be  applied 
to  the  periphery  of  the  wound,  scarified  cups  to  the  temples 
and  hypochondrium,  an  emollient  cataplasm  to  the  head; 
besides  which  pediluvia,  injections  and  diluents  were  success- 
ively employed.  In  spite  of  all  these  measures,  inflammation 
went  on  rapidly  increasing,  the  pain  in  the  side  became  lanci- 
nating and  steady;  the  patient  soon  after  had  rigors  and  cold 
sweats  preceding  the  accession  of  a  fever  of  a  dangerous  type; 
he  died,  at  length,  in  the  night  of  the  thirtieth  to  the  thirty- 
first  day  after  receiving  the  wound. 

We  found,  upon  opening  the  corpse,  the  pericranium  in  such 
a  state  of  inflammation  that  its  blood  vessels  might  be  said  to 
have  been  injected  with  some  fine  fluid.  That  part  of  the  dura 
mater  which  corresponded  with  the  wound  internally,  was 
red  and  tumefied;  the  brain  was  diseased  nowhere,  nor  was 
there  any  serum  in  the  ventricles.  A  very  considerable 
quantity  of  purulent  matter,  proceeding  from  the  bursting  of 
an  enormous  abscess  of  the  convex  part  of  the  liver,  had  dis- 
charged itself  into  the  abdominal  cavity.  The  purulent  nidus 
extended  far  into  the  substance  proper  of  the  liver.  The  proxi- 
mate cause  of  the  death  of  this  subject  may  be  referred  to  his 
twofold  disease,  but  especially  to  that  of  the  liver. 

Third  Observation. — A  dragoon  of  the  guards  had  received 
a  sabre  wound  on  the  head  which  had  taken  ofl^  a  part  of  the 
integuments  and  a  pretty  tliick  lamina  of  the  right  lateral  part 
of  the  occipital  bone.  The  injury  not  seeming  ta  be  of  any 
great  account,  he  had  been  accommodated  in  the  convalescent 
ward,  and  given  in  charge  to  the  surgeon  of  the  ward.  A 
simple  dressing  was  applied.  He  passed  the  first  two  weeks 
without  any  remarkable  occurrence;  the  wound  was  in  very 
good  condition,  and  had  begun  to  cicatrize  from  its  circumfer- 
ence, when  all  at  once  symptoms  of  inflammation  supervened 
and  the  right  hypochondrium  became  painful.  To  these  there 
was  at  first  no  attention  paid,  and  they  became,  therefore,  so 
rapidly  developed  that  the  fever  and  the  inflammation  of  the 
edges  attained  their  highest  degree.     The  pain  in  the  side 


abscesses  0/  the  Liver  a/ier  Injuries  of  the  Head.       193 

also  became  more  intense  and  pulsating.  No  disturbance  in  the 
functions  of  the  brain  was  perceptible,  nor  was  there  any  symp- 
tom of  effusion. 

Such  was  the  condition  of  this  man,  when  we  were  called  to 
see  him:  local  depletion,  refrigerants,  pediluvia  and  antispas- 
modics produced  merely  a  momentary  and  but  slight  relief, 
and  the  patient  died  on  the  thirty-seventh  day  after  admission 
into  the  hospital. 

In  the  progress  of  the  autopsical  examination  we  discovered, 
1st,  a  violent  inflammation  of  the  pericranium;  the  part  of 
bone  originally  cut  into  and  the  coi'responding  portion  of 
the  dura  mater  participating  in  this  inflammation;  2d,  a  pretty 
extensive  abscess  on  the  concave  surface  of  the  liver,  part  of  its 
purulent  matter  having  discharged  itself  already  into  the  ab- 
dominal cavity. 

Fourth  Observation. — A  grenadier  had  received  a  longi- 
tudinal wound  on  the  right  lateral  region  of  the  forehead,  in 
consequence  of  a  sabre  cut  which  had  divided  the  external 
table  of  the  frontal  bone  as  far  as  its  diploe.  He  displayed  at 
first  some  symptoms  of  concussion;  still  he  did  not  fall  down 
immediately,  nor  did  he  lose  his  consciousness  till  several  mo- 
ments afterwards.  The  first  six  days  passed  off  without  any 
further  accident;  but  about  that  time  he  complained  of  some 
acute  and  steady  pain  near  the  bottom  of  the  wound,  which 
had  suddenly  ceased  suppurating.  There  was  somnolency 
interrupted  by  convulsive  movements  and  slight  fits  of  deli- 
rium; whilst  at  the  same  time  he  experienced  an  oppression 
and  a  dull  and  constant  pain  in  the  right  hypochondrium. 
Local  depletion,  mucilaginous  diluents,  and  emollient  appli- 
cations externally  reduced  the  inflammation;  but,  independent 
of  the  symptoms  already  enumerated,  those  of  compression 
now  manifested  themselves;  the  patient  had  lost  the  use  of  the 
left  arm,  while  the  leg  of  the  same  side  was  in  a  state  of  almost 
continued  mobility.  Although  he  suflered  the  most  excru- 
ciating pains  froffi  his  wound,  yet  he  would  always  lie  on  that 
side.  These  symptoms  induced  us  to  apply  the  crown  of  a 
trephine  to  the  most  oblique  point  of  the  fracture.  The  open- 
ing being  made,  there  issued  from  it  a  common  table-spoonful 
Z 


194    Abscesses  of  the  Liver  after  Injuries  of  the  Head. 

of  purulent  matter,  mixed  up  with  small  clots  of  grumous  blood, 
which  had  been  lodged  between  the  cranium  and  the  dura  ma- 
ter, which  latter  it  depressed  to  the  extent  of  about  four  lines 
in  depth. 

In  order  to  act  upon  the  affection  of  the  liver,  which  was 
distinguished  sufficiently  by  the  preternatural  protrusion  of 
the  right  hypochondrium,  by  the  pulsating  pains,  the  irregular 
rigors  and  the  frequent  inclination  to  vomit,  we  directed  a 
blister,  besprinkled  with  cantharides  and  camphor,  to  be  laid 
over  the  region  of  that  organ.  The  patient  was  instantaneously 
relieved;  but  this  tranquillity  was  not  of  long  duration,  for  it 
was  soon  succeeded  by  well  marked  symptoms  of  adynamia, 
as  cold  sweats,  small  pulse,  colliquative  diarrhœa,  tumefaction 
of  the  abdomen,  difficulty  of  breathing  and  gangrene  of  the 
wound.  Death  followed  close  upon  this  gloomy  catastrophe, 
and  again  enabled  me  to  confirm  my  opinion  on  the  cause  of 
abscesses  of  the  liver,  supervening  upon  injuries  of  the  head 
without  any  previous  fall  or  other  violent  concussion.  In 
fact  we  found,  on  opening  the  abdomen,  a  collection  of  puru- 
lent matter  above  the  transverse  mesocolon,  which  proceeded 
from  an  enormous  abscess  situated  in  the  substance  of  the 
great  lobe  of  the  liver,  very  near  the  suspensory  ligament. 
On  inspecting  the  cranium,  we  discovered  also,  independent 
of  the  purulent  deposition  of  the  dura  mater,  a  phlogose 
condition  of  this  membrane,  and  a  suppurated  spot  in  that 
part  of  the  brain  which  corresponded  with  the  latter. 

We  deem  it  necessary  to  observe  that  none  of  these  patients 
had  fallen  at  the  very  moment  of  the  accident,  or  that  they  had 
been  bled  from  the  foot;  the  three  last,  according  to  their  own 
statement,  enjoyed,  moreover,  perfect  health  previously  to  the 
occurreiice  of  their  misfortune.  Doctor  Aumont,  one  of  the 
principal  medical  assistants  of  the  hospital,  opened  the  bodies 
of  the  two  last  subjects.  They  are  not  the  only  ones  which 
we  possess  on  the  subject  under  discussion,  but  we  have  thought 
proper  to  limit  ourselves  to  those  of  which  ^e  have  given  an 
account. 

Now,  in  order  to  resume  what  we  have  said,  concerning 
the  causes  of  abscesses  of  the  liver,  supervening  upon  injuries 
of  the  head,  we  arrive  at  the  conclusion: 


Of  Jlpnplexy.  195 

1.  That  these  abscesses  but  very  rarely  recognize  for  their 
essential  cause  a  direct  and  violent  shock  or  pressure  of  the 
liver,  caused  by  the  fall  of  the  individual,  or  by  any  other 
contunding  body  which  may  have  struck  the  right  hypochon- 
drium.  * 

2.  That  the  causes  of  these  abscesses  after  injuries  of  the 
head  ought  to  be  referred  to  the  sympathetic  irritation,  com- 
municated to  this  organ  by  the  inflammation  established  in  the 
fibrous  membranes  of  the  cranium  or  of  the  bones  of  the  supe- 
rior or  inferior  extremities,  particularly  of  the  same  side,  and 
to  the  ichorous  miasmata,  or  to  some  fluid  more  or  less  acri- 
monious and  subtle,  conveyed  to  this  organ  by  metastasis. 

3.  That  to  all  appearances  any  communication  of  the  mor- 
bific principles  of  the  affected  parts  with  the  liver  is  more 
readily  accomplished,  if  they  shall  not  have  to  pass  the  median 
line  of  the  body. 

The  arguments,  and  the  facts  by  which  we  have  supported 
them,  would  seem  to  reduce  the  important  question  which  we 
have  discussed;  and  we  believe  to  have,  at  least,  traced  the  road 
to  be  pursued  by  practitioners  who  are  desirous  to  test  the 
principles  best  suited  to  settle  this  point. 

Of  JlpopUxy. 

We  deem  it  right  to  combine  with  the  account  just  given 
of  the  traumatic  lesions  of  the  encephalon,  a  very  succinct  view 
of  the  sanguineous  and  serous  congestions  which  are  apt  to 
occur  in  the  ventricles  of  the  brain,  underneath  the  cere- 
bellum, in  the  direction  of  the  medulla  oblongata  and  within 
the  membranes  of  the  spinal  marrow. 

If  these  congestions  are  developed  to  such  an  extent  that 
they  impair  the  sensibility,  the  muscular  contractility,  and  the 
integrity  of  the  sensitive  and  intellectual  functions  of  the 
patient,  they  constitute  what  is  termed  apoplexy,  which  may 
be  distinguished  in  serous  apoplexy  and  sanguineous  apoplexy. 

Serous  congestions,  though  rather  rare,  consist  in  an  abnor- 

*  If  it  should  happen  perchance  that  in  the  fail  of  an  indivi(]iial  the  whole 
weight  of  the  body  bears  upon  the  right  hypochondrium,  the  liver  may  sustain 
some  alteration,  be  lacerated  perhaps;  but  then  such  alteration  would  be  independ- 
ent altogether  of  the  injuries  of  the  head,  as  wc  have  demonstrated. 


196  Of  apoplexy. 

mal  and  more  or  less  considerable  accumulation  of  the  cerebro- 
spinal fluid  which  circulates  in  the  cavities  of  the  encephalon, 
in  an  undulating  manner,  as  circumstances  may  be;  that  is  to 
say,  it  may  pass  from  the  lateral,  the  third  and  fourth  ventri- 
cles into  the  spinal  canal,  and  vice  versa,  by  circulating  in 
these  cavities  between  the  pia-mater  and  the  arachnoid  mem- 
brane.     This   fact   was  perfectly  well  known  to  the  older 
physicians.     The  fluid  accumulated  in  these  cavities,  forms  in 
children  congenital  hydrocephalus,  which  is  sometimes  accom- 
panied by  spina  bifida.     The  patient  may  survive  the  gradual 
development  of  this  species  of  dropsy,  particularly  if  it  has 
been  developed  previously  to  the  complete  ossification  of  the 
bones  of  the  cranium.     If,   however,  the  serous  collection 
occurs  suddenly  in  the  ventricles  of  persons  whose  fontanels 
have  become  obliterated,  its  consequences  are  then  more  dis- 
astrous, and  if  it  have  arrived  at  a  very  high  degree  of  inten- 
sity, it  is  designated  by  the  name  of  hydrocephalitis  or  serous 
apoplexy.     A  collection  of  pus,  formed  in  some  point  of  the 
encephalon,  may  give  rise  to  the  same  phenomena  and  be  at- 
tended by  the  same  results.     In  all  cases  it  is  easy  to  distin- 
guish this  congestion  from  the  sanguineous  congestion  by  the 
preceding  events  and  by  the  symptoms  which  are  its  peculiar 
characteristics;  these  are  discoloration  of  the  skin,  wanness  of 
countenance,  pallor  of  the  lips  and  tongue,  small  and  languid 
pulse,  heaviness  of  the  head,  abnormal  dilatation  of  the  pupils, 
paralysis,  in  various  degrees,  of  the  inferior  extremities  or  of 
one  half  of  the  body,  and  if  the  collection  be  confined  to  the 
cavities  of  cne  side  only  of  the  brain,  restraint  and  slowness 
of  the  functions  of  respiration  and  digestion.     If  such  patients 
incline  the  head  forward,  they  are  apt  to  lose  their  balance, 
and  faint;  the  sensitive  and  intellectual  functions  are  usually 
impaired  in  proportion  as  to  the  efiect  of  the   unequal  com- 
pression  which   the   accumulated   serum  produces  upon  the 
origin  of  the  nerves. 

Sanguineous  depletion  is  not  indicated  under  such  circum- 
stances, but  there  is  the  most  urgent  necessity  for  the  applica- 
tion of  revulsives  to  the  base  of  the  cranium  and  of  derivatives 
to  the  lower  extremities,  and  for  inducing  emesis,  if  the  stomach 
should  be  overloaded  with  alimentary  matter,  not  indeed  by 


Of  Jlpoplexy.  1 97 

means  of  emetics,  for  they  would  not  operate  on  the  stomach, 
paralysed  as  its  powers  are  from  the  want  of  stimulus  which 
the  pneumo-gastric  nerve  is  incapable  of  transmitting  or  trans- 
mits only  imperfectly,  but  by  mechanical  irritation  excited  by 
the  introduction  into  the  gullet,  or  entrance  of  the  pharynx, 
of  the  feathers  of  a  goose  or  swan's  quill.  This  remark  is 
of  the  greater  importance,  as  those  emetics  which  have  not 
acted  upon  the  stomach,  may  give  rise  to  the  subsequent  de- 
velopment of  a  proportionate  inflammation  of  the  mucous 
membrane  of  the  intestines,  whereby  sometimes  the  success  of 
such  other  remedies  might  be  defeated  as  could  have  been 
advantageously  employed  for  the  purpose  of  removing  the  con- 
gestion of  the  brain. 

The  diagnosis  of  sanguineous  apoplexy  may  be  assisted  in- 
dependently of  the  knowledge  of  the  idiosyncrasy  of  the  pa- 
tient, and  of  all  that  may  have  preceded  the  accident,  by  the 
injected  condition  of  the  vessels  of  the  conjunctiva,  the  red- 
ness of  the  face,  turgidity  of  the  veins  of  the  head  and  neck, 
by  the  tendency  of  the  former  to  sink  upon  the  chest,  the 
thickness  and  redness  of  the  tongue,  if  it  be  visible  at  all,  by 
the  fulness,  the  tension  and  slowness  of  the  pulse,  or  the  pulsa- 
tions of  the  arteries,  the  more  or  less  extensive  malformation 
of  the  neck  and  the  general  repletion  of  the  patient.  As  to 
the  colour  of  the  face,  particular  care  should  be  taken  not  to  be 
deceived  by  it;  for  it  frequently  happens  that  the  face  is  dis- 
coloured, although  the  congestion  be  of  a  sanguineous  nature. 
This  occurs,  for  instance,  when  it  suddenly  takes  place,  and 
when  the  eflects  of  the  deep  seated  compression  have  almost 
simultaneously  suspended  the  action  of  the  heart,  so  that  the 
cutaneous  capillaries  of  the  face  could  not  be  injected  by  the 
contraction  of  its  ventricles.  Of  this  we  have  seen  a  great 
many  examples,  while  the  other  symptoms  may  always  be 
satisfactorily  traced  by  the  eyes  of  the  anatomical  physician. 

Supposing,  then,  we  have  formed  a  correct  prognosis,  it  is 
urgently  required  to  unload  the  vessels  of  the  head,  and  the 
most  efficacious  depletion  that,  under  such  circumstances,  can 
be  made,  is  to  open  the  jugular  vein.  Tlie  reasons  for  it  will 
be  explained  in  the  proper  article  concerning  (his  species  of 


198  OfApophxy. 

bleeding,  which  may  be  succeeded  by  scarified  cups  placed 
over  the  nape  of  the  neck,  along  both  sides  of  the  spine,  and 
over  the  dorsal  regions.  Some  should  be  applied  also  over 
the  epigastric  and  hypochondriac  regions,  for  the  purpose  of 
emptying  the  vessels  of  the  stomach  and  of  the  lungs,  and  of 
rallying  the  vital  properties  of  these  organs.  After  these 
depletions,  ice  is  to  be  placed  upon  the  head,  in  order  to  con- 
dense the  fluids  circulating  in  the  vessels  of  the  brain,  and  to 
promote  the  re-absorption  of  those  which  constituted  the  con- 
gestion. Derivative  applications  to  the  legs  or  soles  of  the 
feet,  may  be  resorted  to  at  the  same  time;  such  as  sinapisms  or 
pediluvia  of  salt-water.  Internally  I  administer  nothing  but 
mucilaginous  diluentsslightly  acidulated,  and  gently  stimulating 
injections,  such  as  soap-water.  Tobacco  clysters,  as  recom- 
mended by  some  writers,  are  injurious,  inasmuch  as  Uiey 
blunt  the  sensibility  of  the  mucous  membrane  of  the  large 
intestine,  after  having  produced  previously  a  sudden  excite- 
ment, which  effect  spreads  over  the  whole  system  of  thp 
nerves  of  relation.  Thus  a  spark  of  vitality  is  not  seldom 
extinguished  when,  on  the  contrary,  it  ought  to  have  been 
kindled  into  action  by  the  remedies  above  indicated,  with 
which  should  be  combined,  moreover,  exposure  to  the  fi'esh 
air,  dry  cups,  frictions  over  the  entire  surface  of  the  body,  and 
the  use  of  alkaline  liniments,  strengthened  by  the  addition  of 
tincture  of  cantharides.  As  soon  as  the  turgescence  is  com- 
pletely removed,  moxas  may  be  put  at  the  base  of  the  cranium, 
and  over  both  sides  of  the  vertebral  column,  the  employment 
of  which  may  be  persevered  in,  taking  care,  however,  to 
observe  the  necessary  precautions.  By  this  treatment,  we  may 
fairly  assert  to  have  saved  the  lives  of  a  great  many  individuals. 
Our  venerable  friend.  Professor  Chaussier,  is  a  remarkable 
instance  of  it.  It  was  to  the  application  of  a  pretty  conside- 
rable number  of  moxas,  which  I,  under  the  eyes  of  his  own 
physician,  M.  Ribes,  put  one  after  another  to  the  base  of  the 
cranium,  that  this  illustrious  physiologist,  at  the  time  of  his 
first  attack,  was  indebted  for  the  almost  complete  restoration 
of  the  vital  properties  to  his  paralysed  extremities. 

In  order  to  overcome  the  paralysis  resulting  from  this  kind 


Injuries  of  the  Cerehellum.  199 

of  apoplexy,  the  application  of  the  moxa  must  be  repeated 
over  the  origin  of  the  paralysed  nerves,  or  against  the  sides  of 
the  base  of  the  brain  subject  to  the  congestion. 

Surely,  the  use  of  the  hot  springs,  or  the  establishment  of 
issues  could  never  compare  with  the  topical  revulsive  on  which 
we  have  dwelled.  The  hot  springs  have  the  great  incon- 
venience of  irritating  all  the  different  systems,  and  of  rarifying 
the  fluids  which  circulate  in  the  vessels  of  the  head,  so  as  to 
produce  consequently  a  new  congestion.  The  artificial  drains 
operate  in  no  way  upon  the  diseased  organs,  and  exhaust  the 
strength  of  the  patient  by  the  copious  suppuration  to  which 
they  give  rise.  Internally,  we  must,  as  in  serous  apoplexy, 
confide  alone  in  the  use  of  mucilaginous  diluents  and  honeyed 
acidulated  drinks. 

Purgatives  are  rarely  indicated. 

The  resolution  or  absorption  of  the  fluids  which  had  caused 
the  distention  of  the  parietes  of  the  ventricles  of  the  brain,  the 
cerebral  substance  itself,  and  the  bones  of  the  cranium,  so  far 
as  they  are  susceptible  (which  occurs  occasionally  in  young 
subjects),  is  attended  afterwards  by  the  approximation  of  these 
parietes,  by  the  condensation  of  the  pulpous  texture  of  the 
encephalon,  and  by  the  successive  and  gradual  reduction  of  the 
cavity  of  the  cranium,  the  invariable  tendency  of  which  is  to  be 
in  proportion  to  the  periphery  of  the  brain.  It  is  difficult  to 
accountfor  the  modus  operandi  of  the  causes  which  produce  this 
phenomenon  ;  but  we  are  convinced  that  this  reduction  in  young 
persons,  is  caused  by  the  re-absorption  of  the  congested  fluid 
of  which  we  have  spoken,  as  it  takes  place  also  in  old  people. 
A  similar  reduction  partially  occurs  also  in  those  individuals 
who  have  been  trepanned,  or  who  have  sustained  a  loss,  more 
or  less  considerable,  of  the  bones  of  the  cranium.  We  have 
had  repeated  opportunities  to  verify  this  fact  in  several  subjects. 

Injuries  of  the  Cerebellum  in  Man. 
We  propose,  in  the  present  article,  to   describe  the  phe- 
nomena which  we  have  observed  in  several  individuals,  who 
had  been  affected  with  organic  lesions  of  the  cerebellum,  and 
we  are  inclined  to  believe  that  the  result  of  our  observations 


200  Injuries  of  the  Cerebellum. 

will  go  far  to  prove  that  this  portion  of  the  encephalon  is  by 
no  means  so  essential  to  the  functions  of  locomotion  of  the 
individual  as  certain  physiologists  have  imagined,  but  that,  on 
the  contrary,  it  appears  to  exert  a  very  marked  vital  influence 
upon  the  organs  of  generation,  as  Doctor  Gall  has  already 
suggested. 

Experience  has  already  made  us  familiar  with  the  fact  that 
acute  inflammation  of  the  cerebellum,  be  it  the  result  of  a 
spontaneous  development,  or  the  effect  of  some  mechanical 
cause,  was  constantly  attended  by  an  exalted  state  of  the  animal 
and  organic  sensibility,  without  the  slightest  disturbance  super- 
vening in  the  intellectual  functions  of  the  patient.  If  the  injury 
be  confihed  to  one  only  of  the  lobes  of  the  cerebellum,  the 
increase  of  sensibility  will  be  perceived  on  the  side  affected, 
and  be  accompanied,  in  various  gradations,  by  acute  pain  at. 
the  occiput,  by  horripilations,  by  gradual  or  convulsive  con- 
traction of  the  muscles  of  the  face,  and  of  the  upper  and  lower 
extremities  of  the  same  side,  together  with  a  sort  of  painful  for- 
mication in  thefingersand  toes.  Vision  isfrequently  disturbed  by 
electric  flashes  of  various  colours,  and  the  patient  grows  irasci- 
ble. The  horizontal  and  reclining  position  is  the  most  agreeable 
to  him;  too  forcible  extension  or  too  long  maintained  elevation 
of  the  trunk  incommodes  him  greatly,  gives  rise  to  convulsions, 
and  not  seldom  to  alarming  syncope.  We  have  observed  that 
the  effects  of  this  vitiated  sensibility  show  themselves  more 
particularly  in  the  posterior  region  of  the  patient  than  in  the 
anterior.  (Thus,  in  traumatic  tetanus,  we  have  remarked,  that 
those  injuries  which  were  situated  any  where  in  front  of  the 
body,  caused  emprosthotonos,  while  those  situated  posteriorly, 
were  invariably  followed  by  opisthotonos.)  With  these  par- 
ticular symptoms  associate  themselves  those  which  are  com- 
mon to  the  inflammation  of  other  organs.  We  shall  at  the 
end  of  this  article,  relate  several  cases  which,  as  it  appears  to 
us,  will  corroborate  all  these  assertions. 

If  the  inflammation  terminates  by  suppuration,  it  is  generally 
established  beneath  the  internal  surface  of  the  pia  mater,  the 
arachnoid  loses  its  transparent  appearance,  and  becomes  thick- 
ened like  coagulated  albumen,  still  there  is  no  red  vessel  to  be 


Injuries  of  tht  Ccrebellitni.  20 1 

seen  in  ils  thickness,  nor  have  we  ever  been  able  to  discover 
a  single  one;  the  purulent  focus  aflcTwards  extends  and  pene- 
trates sometimes  into  tiic  substance  proper  of  the  cerebellum, 
so  as  to  consume  the  cortical,  and  giadually  also  the  medullary 
matter  of  the  arbor  vitae.  A  continued  febrile  excitement, 
with  slight  intermissions,  a  dull  and  fixed  pain  at  the  occiput, 
with  a  sense  of  weight  in  the  head,  which  the  patient  seeks  to 
repose,  on  the  injured  side,  upon  the  pillow  of  his  bed;  the  loss 
of  hearing  of  the  same  side;  the  failure  of  speech,  or  difficulty 
of  pronunciation;  and,  finally,  the  consciousness  of  the  cause 
from  which  the  abscess  has  resulted,  are  so  many  symptoms 
by  which  this  morbid  condition  is  characterized:  there  is, 
however,  one  circumstance  deserving  to  be  noticed,  namely, 
that  during  the  existence  of  such  abscesses,  whose  career  we 
have  watched  in  the  subjects  of  the  subjoined  observations, 
we  have  never  witnessed  on  one  side,  more  than  on  the  other, 
any  particular  symptom  of  a  sensible  change  in  the  muscular 
contractility,  or  in  the  animal  sensibility.  This  is  the  more 
remarkable,  as  in  other  persons  who  had  received  wounds  on 
the  occipital  region,  combined  with  injury  of  the  cranium,  and 
effusion  underneath  the  tentorium  of  the  cerebellum,  exerting 
thus  mechanical  pressure  upon  one  of  its  lobes,  we  have 
observed  that  the  upper  arm  of  the  same  side,  evidently  had 
become  paralysed.  There  can  be  no  doubt,  that  the  conse- 
quences of  such  pressure  bear  upon  the  origin  of  those  nerves, 
arisino-  from  the  medulla  oblongata,  which  are  the  most  in 
contact  with  the  fluid  or  substance  causing  the  pressure;  of 
this  class  are  in  particular  the  hypoglossal  nerves. 

When  the  paralysis  has  attained  a  very  high  degree,  it  in- 
variably settles  upon  the  parts  of  the  afiectcd  side,  which  may 
be  explained  by  reference  to  the  anatomical  relations  of  the 
cerebellum  and  its  medullary  productions,  which  display  no 
decussation  or  other  interlacing  whatever;  we  possess,  in  this 
respect,  a  great  many  examples  which  undeniably  prove  the 
correctness  of  these  facts. 

If  the  cause  which  alters  the  substance  of  the  cerebellum, 
exerts  no  mechanical  pressure  upon  the  origin  of  the  hindmost 
nerves  of  the  medulla  oblongata,  there  will  be  no  paralysis, 
2  A 


202  Injuries  of  the  Cerebellum. 

and  the  genital  organs  alone  seem  to  bear  the  effects  of  this 
morbific  affection.  During  the  first  stage  of  inflammation,  the 
animal  and  organic  sensibility  is  increased,  then  blunted,  and 
at  last  gradually  extinguished.  The  same  holds  with  the 
powers  of  motion,  which  exhibit  at  first  an  abnormal  and 
occasionally  tetanic  contractility,  combined  with  swelling; 
next  a  falling  away  and  contraction  of  the  motor  fibre;  and 
finally  are  attacked  with  atrophy,  after  which  the  disease  ex- 
tends to  the  spinal  marrow,  through  the  fluid  there  effused, 
which  previously  compressed  the  medulla  oblongata.* 

These  symptoms  are  subsequently  joined  by  a  troublesome 
dyspnœa,  together  with  engorgement  of  the  organic  vessels  of 
the  lungs,  but  very  frequently  a  more  or  less  severe  attack  of 
hemoptysis  supervenes,  and  continues  in  spite  of  all  the  reme- 
dies which  are  indicated  and  employed  with  the  utmost  care, 
until  the  causes  of  compression  are  removed  by  absorption.  It 
would  seem  in  this  case,  that  the  lungs  are  deprived  of  the 
stimulus  requisite  for  the  performance  of  the  functions  of 
respiration.  If  resolution  takes  place  spontaneously,  or  in 
consequence  of  the  operation  of  topical  revulsives,  seasonably 
applied,  as  near  as  can  be,  to  the  seat  of  the  effusion,  and  if  the 
patient  recovers,  w^hich  is  a  very  rare  occurrence,  he  will  com- 
monly be  subjected  to  some  remarkable  infirmities,  such  as  a 
feeling  of  excessive  tenderness  in  the  neck  and  occipital  region, 
a  decided  asthenia  of  the  genital  organs,  combined  with  atrophy 
of  the  testicle  of  the  side  which  corresponds  to  the  diseased 
lobe  of  the  cerebellum,  or  of  both,  if  the  whole  of  this  part  of 
the  encephalon  be  affected.  In  the  case  of  Raymond  which 
has  been  related  elsewhere  (see  p.  134),  we  have  a  striking 
proof  of  the  truth  of  this  last  assertion. 

The  organs  of  generation  in  their  turn,  likewise,  appear  to 
exercise  a  marked  influence  upon  the  cerebellum;  for  when 
they  have  been  removed  by  disease  or  some  other  cause,  the 
occipital  region  of  the  cranium  and  cerebellum  gradually  un- 

*  Concerning  the  arrangement  and  communication  of  the  ventricles  of  the  brain 
with  the  spinal  marrow,  see  the  great  work  of  Wenzel,  "  Structura  cerebri 
homiais  et  brutorum." 


Injuries  of  the  Cerebellum.  203 

dergoes  a  reduction  so  sensible  that  the  occipital  protuberances, 
more  or  less  prominent  before  the  accident  or  disease  which 
befell  tlie  genital  organs,  disappear,  and  the  whole  occipital 
region  of  the  head  is  reduced  in  proportion.     We  have  verified 
this  alteration  by  reduction  in  a  great  many  soldiers   who, 
at  periods  more  or  less  advanced,  had  been  operated  upon  for 
sarcocele.     When  the  person  had  lost  only  one  of  the  genital 
organs,  the  decline  of  the  cerebellum  and  of  the  occipital  pro- 
tuberance which  corresponds  with  the  lobe  of  the  cerebellum, 
will  be  confined  to  the  side  of  the  extirpated  organ.     (Compare 
with  these  remarks  the  article  on  *'  the  Diseases  and  Injuries 
of  the  Genital  Organs,"  in  the  Clinique  Chirurgicale,  Vol.  III.) 
Treatment.   The  affections  of  the  cerebellum,  occasioned  by 
external  mechanical  causes,  ought  to  be  treated  with  the  utmost 
attention.     The  first  indications  in  this  respect  to  be  fulfilled, 
are  to  dilate  the  wound  of  the  external  soft  parts,  if  there  be 
one;  to  extract  the  foreign  bodies  or  portions  of  bone  denuded 
of  pericranium,  if  any  such  should  be  encountered;  to  approxi- 
mate the  edges  of  the  wound  by  means  of  a  piece  of  perforated 
linen,  thinly  spread  with  some  tenacious  and  balsamic  sub- 
stance, and  to  apply  over  it  a  simple  dressing,  such  as  the 
bandage  of  Galen.     If,  after  the  first  dressing,   symptoms  of 
sanguineous  plethora  make  their  appearance,  general  and  topi- 
cal bleeding,  from  the  temporal  artery  and  the  veins  of  the 
extremities,  as  well  as  by  scarified  cups  to  the  neck  and  between 
the  shoulders,  must  be   had  recourse  to.     These  measures, 
which  ought  to  be  repeated  pro  re  nata,  may  be  followed  up 
by  mustard  pediluvia,  by  the  application  of  ice  upon  the  head, 
and  the  exhibition  of  cooling  and  mucilaginous  drinks. 

The  hydrocyanic  acid,  so  much  extolled  latterly  in  all  in- 
flammations of  the  head,  we  have  ourselves  tried  in  every 
way  ;  but  it  has  constantly  appeared  to  us  to  have  been  injurious; 
for,  when  given  in  the  smallest  dose,  it  sometimes  produces 
colic  and  bloody  discharges.  This  was  more  particularly 
observed  by  us  in  the  case  of  Raymond. 

Observations.  In  order  to  support  our  remarks  on  the 
various  afiections  of  the  cerebellum  described  by  us,  we  now 
propose  to  relate  several  cases  which  we  have  collected. 


204  Injuries  of  the  Cerebellum. 

One  of  the  most  curious  cases  of  inflammation  of  the  cere- 
bellum, is  that  of  a  soldier  of  the  army  of  Egypt,  eighteen 
years  old,  who,  at  the  moment  when  the  vessel,  in  entering  the 
harbour  of  Alexandria,  fired  a  salute,  was  struck  by  a  splinter 
of  wood  on  the  neck,  from  which  resulted  a  violent  contusion, 
with  ecchymosis  of  the  whole  occipital  region.  He  was 
carried  to  the  ambulance  in  that  city,  wiiere  he  remained  seven- 
ty-five days.  This  man  instantly  displayed  the  symptoms  of 
intense  inflammation  everywhere  beneath  the  parts  afiected, 
but,  above  all,  in  the  cerebellum.  The  pain  in  the  occiput, 
which  was  excessive,  did  not  abate  till  an  abscess  at  the  neck 
opened  spontaneously.  The  patient,  whose  life  had  been  in 
danger,  told  us,  that  during  the  treatment  of  his  disease,  and 
long  after  his  recovery,  he  could  not  move  the  head,  and  that 
he  felt  an  extreme  tenderness  throughout  the  whole  cervical 
region,  so  as  to  unfit  him  to  bear  the  slightest  touch  upon  it. 
The  inflammation  yielded,  however,  to  repeated  bleedings,  to 
ablutions  of  the  head  with  cold  water,  and  to  cooling  and 
diluent  drinks;  he  finally  recovered,  and  three  months  after 
the  occurrence  of  the  accident,  he  rejoined  his  half-brigade  at 
Cairo,  in  which  he  continued  to  serve  till  his  return  to  France 
with  the  remainder  of  our  expedition.  Several  years  having 
elapsed,  when  this  soldier  came  before  the  Board  of  Health 
of  the  hospital  of  Gros  Caillou  in  order  to  solicit  his  discharge, 
we  mistook  him,  at  first,  for  a  young  conscript,  who  had  been 
exhausted  by  some  asthenic  disease;  he  was  then  thirty-two 
years  old,  of  middle  size,  thin  and  emaciated;  he  looked  pale 
and  somewhat  wrinkled,  his  eyes  were  depressed,  the  lips 
blanched,  his  hair  scanty  and  bristled,  particularly  that  cover- 
ing the  occipital  region,  where  he  continually  felt  a  sensation 
of  pain  and  habitual  coldness;  yet  his  mental  faculties  had 
never  sustained  the  slightest  alteration.  He  was  beardless, 
and  his  voice  was  shrill  and  feminine.  Some  of  the  assistants, 
at  first,  suspected  a  woman  to  have  served  in  the  dress  of  a 
soldier,  of  which  there  are  so  many  examples  on  record. 
By  a  more  minute  examination,  we  were  enabled  to  verify 
his  sex,  and  to  our  great  surprise,  we  found  his  genital  organs 
reduced  to  the  size  of  those  of  an  infant  some  months  old,  his 


Injuries  of  the  Cerebellum.  205 

penis  measured  five  or  six  lines  at  most,  by  two  or  three  in 
diameter,  and  never  experienced  the  least  erection;  his  testicles 
were  almost  gone,  and  wasted  to  such  a  degree,  as  scarcely  to 
equal  in  size  a  small  kidney-bean. 

This  individual  who  at  the  time  of  his  discharge,  in  IS  10, 
was  introduced  to  Doctor  Gall,  declared  that  ever  since  he  had 
met  with  this  accident,  he  had  lost  every  kind  of  sexual  desire 
and  erection,  and  that  his  beard,  which  previously  had  been 
thick,  had  disappeared  by  degrees.  He,  like  all  young  fellows 
of  his  age,  had  also  previously  enjoyed  the  powers  of  virility. 

Another  not  less  curious  instance  was  furnished  us,  in  the 
person  of  the  Sieur  François  Auguste,  quarter-master  to  the 
horse  artillery  of  the  ex-guards,  who,  during  the  action  of 
Benevent  in  Spain,  in  1809,  had  been  struck  by  the  ball  of  a 
blunderbuss,  which  crossed  from  one  side  to  the  other  the 
extensor  muscles  of  the  head,  by  grazing  the  occipital  protu- 
berances, which,  being  remarkably  prominent  in  this  subject, 
were  thereby  deprived  of  their  aponeurotic  adhesions.  The 
two  openings  made  by  the  ball  were  dilated,  which  enabled 
us  to  pull  out  part  of  his  shirt  collar  which  had  remained  behind 
in  the  track  of  the  projectile.  The  dressing  of  these  wounds 
was  made  as  the  nature  of  the  circumstances  required. 

The  patient  immediately  felt  a  violent  pain  in  his  occiput, 
and  a  sense  of  weight  of  the  whole  head,  together  with  numb- 
ness of  the  lower  extremities.  His  vision  and  hearing  were 
so  much  impaired  that  he  could  hardly  discern  any  large  objects 
or  understand  the  most  piercing  soynds.  His  testicles  became 
reduced,  and  wasted  away;  his  penis  diminished  in  the  same 
proportion  and  remained  motionless.  The  local  symptoms 
were  dispersed,  and  the  patient  was  restored  to  health  before 
the  expiration  of  the  fiftieth  day. 

The  subject  of  the  third  observation  was  a  man  of  the  name 
of  René  Bigot,  a  chasseur  of  the  horse  guards,  of  a  robust  con- 
stitution and  passionately  fond  of  women.  In  the  same  action 
of  Benevent  he  had  received  a  sabre-wound  which  had  divided 
the  whole  projecting  or  convex  part  of  the  occipital  bone  as 
far  as  the  dura  mater,  a  small  portion  of  which  had  been  cut 
into.     The  right  lobe  of  the  cerebellum  could  be  seen  through 


206  Injuries  of  the  Cerebellum. 

the  opening  into  this  membrane.  The  slightest  touch  of  this 
organ  gave  rise  to  vertigo,  syncope  and  convulsions,  without 
the  patient  evincing  the  least  sign  of  pain.  Before  dressing 
the  wound,  we  took  the  precaution  to  make  an  incision  at  the 
base  of  the  flap  in  order  to  facilitate  the  discharge  of  the  fluids. 
That  part  of  it  which  corresponded  with  the  opening  into  the 
meningeal  covering,  formed  no  adhesion,  because  of  the  incess- 
ant oozing  from  the  internal  surface  of  that  serous  membrane; 
otherwise  there  was  no  further  effusion.  These  fluids  escaped 
at  every  dressing  in  small  bubbles,  and  produced  a  faint  whiz- 
zing noise,  which  we  attributed  to  the  external  air  passing  in 
and  out  through  the  same  opening.  After  the  first  few  days 
the  patient  lost  the  faculty  of  vision  and  hearing  of  the  right 
(or  affected)  side;  at  the  same  time  he  suffered  violent  pain 
along  the  course  of  the  spine,  and  a  kind  of  formication  in 
the  testicles,  the  size  of  which  most  rapidly  decreased;  for, 
in  less  than  a  fortnight,  the  right  testicle,  in  particular,  was 
reduced  to  the  size  of  a  small  Windsor  bean,  and  he  soon  lost 
even  the  thoughts  and  the  recollection  of  the  pleasures  which 
he  had  enjoyed  wûth  so  many  women. 

The  journey  from  Benevent  to  Valladolid  he  had  borne  very 
well.  His  wound  was  in  every  other  way  in  the  best  possi- 
ble condition,  and  with  the  exception  of  the  functions  of 
vision,  hearing  and  generation,  which  appeared  to  be  lost  for 
ever,  we  entertained  some  hope  of  his  recovery.  However, 
a  new  train  of  inflammatory  symptoms  became  established, 
and  went  on  increasing  progressively,  notwithstanding  the  an- 
tiphlogistic measures  which  we  employed  to  overcome  them. 
The  pain  in  the  head  and  spine  caused  the  patient  to  utter  the 
most  doleful  screams;  he  was  continually  drawn  up  in  his  bed, 
lying  on  the  same  side  with  the  wound;  the  slightest  move- 
ment caused  him  to  have  convulsions,  and  whenever  he  raised 
himself  up  for  the  performance  of  his  alvine  functions,  he 
would  fall  into  frightful  syncopes;  as  a  last  resort,  I  ordered 
the  application  of  a  large  blister  between  the  shoulders,  and 
prescribed  cooling  and  mucilaginous  drinks;  but  he  grew 
worse  from  day  to  day;  he  was,  finally,   attacked  with  opis- 


Injuries  of  the  Cerebellum.  207 

Ihotonos,  and  expired  February  filli,  1809,  on  lite  lliirty-ninlli 
day  after  he  had  met  with  this  accident. 

During  the  autojDsical  examination  wc  made  the  following 
discoveries:  the  occipital  bone  iiad  sustained  a  considerable 
loss  ot"  substance;  the  slit  into  the  dura  mater,  to  which  we 
have  alluded,  corresponded  to  the  centre  of  the  right  lobe  of 
the  cerebellum,  which  had  sunk  downwards  and  was  of  a  yel- 
lowish colour,  but  free  from  suppuration  or  effusion.  The 
medulla  oblongata  and  spinal  marrow  bore  a  dull  white  aspect, 
were  of  a  greater  consistence  tiian  is  natural,  and  had  lost  about 
a  quarter  of  their  size;  the  nerves  arising  from  them  appeared 
to  us  also  to  be  in  a  state  of  atrophy  near  their  origin. 

Wc  are  authorized  to  infer  from  this  pathological  fact,  that 
the  first  and  chief  result  of  inflammation  of  the  brain  is,  as  we 
have  seen  repeatedly  confirmed,  the  hardening  of  the  cerebral 
and  nervous  substances,  whilst  atrophy  and  ramollissement 
are  merely  its  consecutive  effects. 

Without  relating  here,  in  full,  the  case  of  Raymond,  of 
whose  complaint  we  have  already  given  (see  p.  134)  a  detailed 
account,  when  we  were  treating  of  the  injuries  of  the  frontal 
sinuses,  we  may  nevertheless  be  indulged  in  repeating:  1,  that 
in  consequence  of  the  violent  fall  of  the  patient  on  the  back 
part  of  the  head,  at  the  time  when  he  had  been  struck  on  the 
superior  orbitar  ridge  of  the  right  side,  he  was  deprived  of  the 
functions  of  vision  and  smelling  of  the  same  side;  2,  that  a 
nervous  excitement  manifested  itself,  which  threw  both  ex- 
tremities of  the  right  side  into  a  state  of  violent  contraction, 
soon  assumed  a  tetanic  character,  and  terminated,  at  last,  by 
atrophy  of  the  two  limbs;  3,  that  the  right  testicle,  after 
becoming  tumefied  and  occasioning  violent  pain  to  the  patient, 
was  reduced  likewise  from  its  original  size  to  almost  total 
disappearance,  without  the  penis  exhibiting,  after  the  accident, 
the  least  sign  of  erection;  4,  that  the  incessant  and  deep  seated 
pain  of  the  patient  in  the  right  lateral  region  of  the  head, 
became  so  intense,  that  he  could  not  bear  the  slightest  touch 
in  that  direction,  without  uttering  screams,  accompanied  by 
horripilations  and  convulsions;  5,  that,  to  our  great  surprise, 
the  hair  and  whisker  of  the  right  side  bristled,  and  conveyed 


208  Injuries  of  the  Cerebellum. 

an  exquisitely  painful  sensation  upon  the  slightest  touch,  or 
on  cutting  the  smallest  number  of  these  hairy  productions, 
although  a  sharp  edged  pair  of  scissors  was  used  for  that  pur- 
pose; 6,  that  this  man  remained  in  this  state  of  contraction 
and  nervous  spasm  during  the  whole  winter  of  1822  to  1823; 
after  which,  upon  the  occasion  of  the  heat  in  the  summer  of 
1823,  a  salutary  revolution  was  suddenly  wrought  in  him, 
which  seems  to  have  been  developed  under  the  influence  of 
copious  sweats,  excited  by  the  heat  of  the  season  and  by  the 
emollient  baths  which  we  had  advised  him  to  use. 

Thus  the  exquisite  sensibility  to  which  he  had  been  subject, 
was  subdued;  he  could  allow  his  hair  to  be  cut,  and  his  beard 
to  be  shaved  without  much  pain;  the  tetanic  contraction  of 
the  hand  and  arm  gradually  diminished;  the  hand  and  fingers 
opened  and  extended;  all  his  nails,  which  had  been  necrosed 
and  were  hideous  to  look  at,  fell  off,  and  were  replaced  by 
others  of  proper  formation;  all  the  other  functions  were  by 
degrees  re-established  and  he,  finally,  returned  home  in  good 
health. 

Now,  that  we  believe  we  have  traced  the  march  of  acute  in- 
flammation of  the  cerebellum,  that  is  to  say,  the  effects  of  the 
physical  lesions  by  which  this  organ  is  liable  to  suffer,  we 
intend  to  exhibit,  in  the  two  next  observations,  the  phenomena 
which  the  same  inflammation  has  presented  to  us,  when  it 
terminates  by  suppuration  and  the  almost  total  destruction  of 
one  of  the  lobes  of  this  part  of  the  encephalon. 

Towards  the  end  of  December  1822,  John  Dureng,  a  work- 
man of  the  third  company  of  artillery  of  the  guards,  aged  24 
year^,  of  a  robust  constitution,  while  engaged  in  carpenter 
work,  was  struck  by  a  piece  of  wood  on  the  right  side  of  the 
head,  where  during  the  first  few  days  he  felt  a  pretty  smart 
pain;  he  continued,  however,  his  occupation  until  January  5th, 
1823,  when  he  was  carried  into  the  fever  ward  of  the  hospital 
of  the  guards,  complaining  of  nothing  but  headach,  without 
assigning  the  cause  which  had  occasioned  it.  A  phlegmonous 
engorgement  having  manifested  itself  behind  the  right  ear 
about  the  eighth  or  ninth  day,  he  was  transferred  to  the  ward 
of  the  wounded  patients.     We  directed  emollient  applications 


Injuries  of  the  Cerebellum.  209 

over  the  tumour,  and  put  the  patient  upon  the  use  of  refrige- 
rant mucilages  and  mild  anodynes  in  order  to  induce  sleep. 
The  abscess  did  not  fail  to  show  itself,  and  from  the  third  day- 
its  fluctuation  became  perceptible.     A  free  incision  into  the 
centre  of  the  tumour  discharged  about  three  ounces  of  whitish 
pus,  mixed  with  clots  of  grumous  blood.     The  opening  of  this 
abscess  exposed   the  whole  surface  of  the  mastoid  process, 
which,  doubtless,  was  the  part  which  had  sustained  the  injury. 
Upon  the  wound  being  unloaded   and  cleansed,  it  cicatrised, 
and  the  patient  recovered.     He  had  lost  his  hearing,  however, 
on  the  same  side,  and  his  pronunciation  was  rather  embarrassed  ; 
at  length  he  was  well  enough  to  leave  the  hospital,  on  April 
5th  following,  it  being  the  third  month  after  his  admission  into 
the  fever  ward,  and  he  repaired  on  foot  to  Vincennes,   the 
place  of  his  garrison.     It  is  to  be  remarked  that,  in  the  course 
of  his  illness,  the  functions  of  his  senses,  with  the  exception 
of  his  hearing  and  speech,  as  well  as  the  intellectual  faculties, 
had  never  been  disordered  in  the  slightest  degree;  all  the  other 
parts  of  the  body   had  alike  preserved  their  integrity   and 
plumpness. 

Two  days  afterwards  we  were  informed  that  this  labourer 
had  been  reported  for  dead  at  the  hospital.  This  was  on  the 
7th  of  April.  We  were  unable  to  obtain  the  slightest  cue  as 
to  what  happened  to  him  before  his  last  accident;  we  only 
learnt  that  after  having  spent  the  day  of  his  arrival  and  the 
next  with  his  comrades,  drank  and  eaten  like  themselves,  he 
had  been  found  dead  on  the  morning  of  the  seventh,  with  his 
head  inclined  on  the  edge  of  his  bed. 

The  first  twenty-four  hours  having  expired,  we  proceeded 
to  open  the  body,  which  was  done  in  our  presence  by  M.  Des- 
ruelles,  one  of  our  assistant  surgeons.  The  body  was  stijQT, 
displaying  his  embonpoint;  the  face  livid  and  swollen.  The 
cranium  being  sawed,  the  sinuses  of  the  dura  mater  were  found 
engorged  with  black  and  fluid  blood  ;  the  membranes  present- 
ed nothing  of  pathological  interest.  The  cerebral  substance 
was  much  more  dense  than  it  is  in  its  normal  state.  The 
lateral  ventricles  and  the  spinal  canal  contained  a  large  quantity 
2   B 


210  Injuries  of  the  Cerebellum. 

of  serum,  to  the  amount,  as  was  estimated,  of  three  or  four 
ounces. 

The  right  hemisphere  of  the  cerebellum  was  entirely  disor- 
ganized by  an  abscess  which  pervaded  its  whole  substance. 
The  purulent  matter  being  of  a  yellowish  white  colour  and 
gelatinous  appearance,  was  enclosed  in  a  kind  of  cyst,  the  thin 
parietes  of  which  were  of  a  pearly  white  aspect;  the  lining  cor- 
responding to  the  base  of  the  cerebellum  was  covered  with  a 
layer  of  coagulated  blood,  and  presented  a  small  fringed  open- 
ing through  which  a  part  of  the  purulent  matter  had  escaped 
into  the  occipital  fossa  in  the  direction  of  the  foramen  magnum. 
The  tubercula  quadrigemina  and  the  opposite  hemisphere  of 
the  cerebellum  were  reduced  from  their  original  or  normal 
size. 

The  viscera  of  the  thorax  and  abdomen  exhibited  nothing 
of  pathological  moment;  but  the  testicle  of  the  affected  side 
had  been  reduced  to  one  half  the  size  of  that  of  the  left  side; 
it  may  be  said  to  have  been  in  the  second  stage  of  atrophy. 

Before  we  indulge  in  any  remark  on  this  disease,  we  shall 
proceed  to  give  an  account  of  the  second  case,  the  principal 
considerations  of  which  iiave  the  greatest  analogy  with  those 
of  the  preceding. 

A  Swiss  soldier,  named  Granfort,  fifty  years  of  age,  was 
admitted  into  the  hospital  in  the  early  part  of  May  1823,  on 
account  of  an  erysipelatous  affection  of  the  whole  left  lateral 
part  of  the  face,  attended  with  habitual  cephalalgia,  a  sense  of 
weight  in  the  head,  a  continual  tendency  to  incline  it  to  the 
affected  side,  deafness  of  the  ear  of  the  same  side,  and  great 
difficulty  of  speech.  His  pulse  was  febrile,  and  his  strength 
appeared  to  be  greatly  reduced.  These  symptoms  had  been 
occasioned  by  a  fall  which  the  patient  had  sustained  on  this 
side  of  the  head  a  few  days  before  the  appearance  of  the  ery- 
sipelas. Emollients  were  applied  to  the  tumefied  parts,  and 
internally  we  prescribed  mucilaginous  diluents,  with  mild  ano- 
dyne draughts  for  the  night. 

After  persevering  for  several  days  in  this  treatment,  a 
marked  fluctuation   became  perceptible  in  the  centre  of  the 


Inji^ries  of  the  Cerebellum.  211 

tumour,  into  which  wc  now  made  a  free  incision  which  ex- 
posed the  whole  extent  of  the  abscess.  The  mastoid  process 
was  denuded  and  perforated  by  a  curious  communication  of 
the  abscess  with  the  internal  ear  and  meatus  auditorius,  through 
which  a  portion  of  the  purulent  matter  escaped.  Five  or  six 
weeks  afterwards  the  walls  of  this  abscess  were  clean;  the 
wound  began  to  cicatrise  from  the  circumference,  and  the  pa- 
tient seemed  to  think  himself  a  good  deal  improved;  still,  he 
complained  always  of  a  sense  of  weight  in  the  head,  of  pains 
in  the  occiput,  with  a  great  tendency  to  rest  it  on  the  affected 
side;  when  standing  he  could  with  difficulty  only  preserve  his 
equilibrium;  he  spoke  seldom  or  never,  and  when  he  did  his 
pronunciation  was  much  impeded.  The  integum.ents  of  the 
occipital  region  and  neck  of  the  same  side  were  very  tender; 
but  the  mental  faculties  remained  unimpaired.  Whenever  he 
could  not  articulate,  which  frequently  happened  to  him,  he 
answered  by  signs  to  every  question  proposed  to  him.  The 
arm  and  the  hand  of  the  left  side  were  threatened  with  para- 
lysis; but  the  motions  of  the  other  limbs  had  in  no  respect 
whatever  experienced  the  least  alteration.  After  about  two 
months  spent  in  a  state  of  irksome  convalescence,  during  which 
he  had  always  exhibited  a  saffron  complexion,  he  suddenly 
relapsed  into  a  state  of  lethargic  drowsiness,  and  expired 
twenty-four  hours  afterwards. 

Thirty  hours  after  death  the  body  was  examined,  which 
operation  was,  in  our  presence,  performed  also  by  the  same 
physician,  M.  Desruelles.  The  cranium,  the  principal  object 
of  our  search,  having  been  opened,  we  found  the  dura  mater 
of  a  deep  brown  colour,  so  many  of  its  proper  blood  vessels 
being  congested  with  black  and  fluid  blood.  The  arachnoid 
was  opaque,  and  in  some  places  of  a  dull  white  appearance. 
The  deep  seated  blood  vessels  of  the  cerebral  substance  were 
injected  also,  and  the  latter  was  of  a  firmer  consistence  than 
natural;  the  lateral  ventricles  contained  a  little  colourless 
serum.  The  brain  being  detached  and  removed  from  the 
cranium,  and  the  tentorium  being  slit  open,  we  found  in  the 
left  lobe  of  the  cerebellum  about  three  tablespoons  full  of  pus 
of  a  whitish  and  gelatinous  aspect,  which  had  encroached  upon, 


212  Injuries  of  the  Cerebellum. 

or  rather  displaced  entirely,  the  hemisphere  of  the  cerebellum; 
this  purulent  substance  was  enveloped  within  the  pia  mater, 
which  had  acquired  a  somewhat  firmer  consistency,  and  as  m 
the  subject  of  the  preceding  case,  assumed  a  pearly  colour. 
The  other  half  of  the  cerebellum  was  shrivelled,  and  the  me- 
dullary substance  forming  the  arbor  vitae,  was  of  a  greyish 
colour  and  very  dense.  Pus  was  effused  into  the  lambdoidal 
fossa  and  beneath  the  pons  Varolii  of  the  medulla  oblongata. 
It  was  in  this  fossa  of  the  base  of  the  cranium  where  we  met 
with  the  carious  spot  which  communicated  w-ith  the  internal 
ear,  and  which  was  surrounded  by  adhesions  of  the  membranes. 

The  stomach  and  the  intestines  exhibited  some  m.arks  of 
chronic  inflammation.  The  liver  being  of  a  green  marbled 
appearance  was  reduced  to  one  half  its  primitive  or  normal 
size,  and  was  lodged  deeply  in  the  hypochondrium;  its  tex- 
ture was  dense,  friable,  and  almost  black.  The  gall  bladder 
was  greatly  distended,  and  full  of  deep  green  and  viscid  bile. 
The  ductus  choledochus  was  much  contracted,  and  the  diame- 
ter of  the  vena  porta  considerably  smaller  than  is  ordinarily 
the  case. 

The  scrotum  and  penis  were  so  much  reduced  from  their 
original  size  that  they  might  be  considered  to  have  been  in 
the  second  stage  of  atrophy. 

It  is  evident  from  the  progress  of  this  slow  inflammation, 
which  may  be  styled  traumatic,  that  in  the  two  last  cases  its 
essential  cause  consisted  in  a  violent  shock  received  on  the 
mastoid  region  of  the  right  side  in  the  first,  and  on  the  left 
side  in  the  second  case.  Although  this  inflammation  had 
terminated  by  copious  suppuration  in  both,  we  observed: 

1.  That  the  intellectual  faculties,  and  (with  the  exception 
of  hearing  and  speech)  the  sensitive  functions,  also,  had  never 
been  distui'bed. 

2.  That  the  organs  of  locomotion  had  not  undergone  a  de- 
cided change  in  any  part  of  the  body,  excepting  very  slightly 
in  the  arm  of  the  Swiss  guardsman,  and  only  tovv'ards  the 
termination  of  the  disease  (on  the  same  side  with  the  affected 
part  of  the  cerebellum). 

3.  That  the  animal  sensibility,  so  far  from    having    been 


Injuries  of  the  Cerebellum.  213 

blunted,  at  least  in  the  posterior  regions  of  the  head  and 
neck,  had  risen  in  both  in  the  early  stages  of  their  complaints, 
and  if  in  the  latter  period  it  had  subsequently  declined,  espe- 
cially in  the  case  of  the  last  subject,  it  was  owing  to  the  circum- 
stance that  the  fever  of  re-absorption,  which  affected  him  in 
the  last  stage  of  the  disease,  had  simultaneously  destroyed  the 
vital  principle  in  every  organ;  so  that  the  patient  had  fallen, 
several  days  before  death,  into  a  state  of  adynamia  or  absolute 
prostration.  With  respect  to  the  first  case,  the  absorption  of 
pus,  contained  as  it  was  in  a  kind  of  cyst,  proceeded  with 
more  difficulty,  and  the  patient  preserved  the  equilibrium  of 
his  vital  functions  up  to  the  moment,  no  doubt,  when  this  pu- 
rulent cyst  actually  burst,  and  when  its  contents  were  diffused 
beneath  the  medulla  oblongata  and  into  the  spinal  canal. 

4.  After  these  facts  and  precedents,  it  is  evident  that  the 
injuries  of  the  cerebellum  necessarily  diminish  and  impair  the 
vital  principle  of  the  organs  of  generation,  weaken  their  func- 
tions, and  induce  in  them  a  state  of  atrophy. 

5.  The  above  facts  prove,  moreover,  contrary  to  the  asser- 
tion of  several  authors,  that  all  injuries  of  the  cerebellum,  even 
when  they  embrace  the  arbor  vitas,  are  not  always  essentially 
mortal. 

I  shall  conclude  now  by  making  some  extracts  from  two  re- 
markable cases  which  form  a  part  of  my  memoir  on  sarcocele. 
The  subject  of  the  first  is  a  drummer  of  the  grenadier  ex-guards, 
about  twenty-seven  years  old,  of  an  athletic  frame,  brown 
complexion,  and  withal,  with  very  handsome  black  mustachios, 
upon  whom,  in  1810,  I  had  operated  for  extirpation  of  the  left 
testicle  which  had  become  cancerous.  This  man,  after  his 
recovery,  returned  to  his  regiment,  made  the  campaigns  of 
1812,  1813  and  1814,  and  always  continued  to  do  the  duties  of 
his  station.  He  repaired  once  more  to  the  hospital  of  Gros 
Caillou  on  account  of  an  obscure  cancerous  affection  of  the 
other  testicle,  which  had  grov,7n  to  the  size  of  the  fist.  After 
having  first  unavailingly  employed  all  the  remedies  which  are 
calculated  to  induce  resolution,  leeches,  dissolvents  (fondans) 
and  mercurials,  we  decided  on  performing  upon  him  a  second 
operation,  which  we  believed  to  be  indispensably  and  urgently 


214  Injuries  of  the  Cerebellum. 

indicated  by  the  lancinating  pains  which  he  almost  continually 
suffered  at  the  diseased  part,  by  the -slow  fever  and  the  state 
of  marasmus  to  which  he  had  been  reduced.  Extirpation 
being  accomplished,  we  discovered,  indeed,  that  the  carcino- 
matous virus  had  attacked  the  entire  substance  proper  of  the 
testicle  and  of  its  epididymis.  We  had  some  difficulty  in  re- 
storing the  general  health  of  this  drummer;  however,  after  seve- 
ral months  rest,  he  was  again  in  a  fit  condition  to  resume  his 
duties,  which  he  would  continue,  notwithstanding  the  loss  ot 
both  his  generative  organs;  after  which  I  finally  lost  sight 
of  him. 

In  1821  the  same  individual  was  again  admitted  into  the 
hospital  for  an  incised  wound  which  he  had  received  in  single 
combat  in  the  right  thigh.  I  had  some  difiiculty  to  recognize 
him;  his  mustachios  had  grown  very  thin,  and  his  physiog- 
nomy become  quite  effeminate  ;  at  length,  in  order  to  put  me 
in  mind  of  him,  he  told  me  that  I  had  operated  on  him  twice, 
the  first  time  ten  years,  and  the  second  time  upwards  of  one 
year  ago.  Being  convinced  of  the  truth  by  an  examination  of 
his  genitals,  I  examined  his  neck,  which  he  informed  me  was 
now  much  less  prominent  than  it  had  been  prior  to  the  first 
operation;  I  noticed,  indeed,  very  plainly,  that  the  sub-occipi- 
tal protuberance  on  the  side  of  the  testicle  which  had  been 
extirpated  first,  was  much  more  depressed  than  that  of  the  op- 
posite side;  and  the  whole  occipital  region  of  this  man  appear- 
ed to  us  to  have  been  considerably  reduced.  In  other  respects 
he  enjoyed  good  health,  and  had  some  embonpoint.  This 
interesting  individual  was  introduced  to  Dr  Gall  by  Dr  Gim- 
melle,  one  of  our  principal  assistants. 

The  second  case  was  I.  B.  Dandé,  a  private  of  the  second 
regiment  of  the  guards,  twenty-six  years  old,  of  a  lymphatic 
temperament  and  scrofulous  diathesis,  who,  in  1823  and  1824, 
had  been  treated  for  rachialgia,  with  caries  of  one  of  the  upper 
dorsal  vertebrae,  and  accompanied  by  an  abscess  from  conges- 
tion which  had  been  developed  behind  and  beneath  the  scapula, 
so  as  to  produce  a  fluctuating  tumour,  of  an  oval  shape,  pro- 
jecting about  three  inches,  and  measuring  seven  in  circumfe- 
rence.     By  means  of  moxas,  the  number  of  w^hich  amounted 


Injuries  of  the  Cerebellum.  215 

to  fifty,  successively  applied,  the  progress  ol"  caries  of  the  ver- 
tebrae was  arrested,  and  the  purulent  matter  of  the  abscess, 
which  depended  upon  it,  was  absorbed.  After  a  residence  of 
seven  or  eight  months  at  the  hospital,  the  patient,  finding 
himself  perfectly  restored  to  health,  at  least  as  to  appearances, 
rejoined  his  regiment  and  again  entered  upon  the  active  duties 
of  the  service.  He  experienced,  however,  continually,  a  slight 
embarrassnrient  in  the  motions  of  the  trunk,  and  whenever  he 
attempted  to  raise  the  arm  of  the  side  of  the  diseased  shoulder. 
He  discovered  also  that  he  had  lost  a  good  deal  of  the  size 
which  he  had  when  he  entered  the  regiment,  which  proves  a 
loss  of  substance  of  the  bodies  of  the  carious  vertebrae  which 
subsequently  could  not  approximate  each  other,  except  by  oc- 
casioning a  shortening  of  the  whole  length  of  the  man,  in  pro- 
portion to  the  loss  of  bony  matter.  At  the  time  of  his  entering 
the  regiment,  Dandé  measured  710  millimètres,  while  on  Feb- 
ruary 10th,  1827,  when  I  caused  him  to  be  measured  again 
with  the  same  measure  and  under  the  same  precautions  as  those 
of  the  regimental  survey,  his  size  amounted  to  67S,  which 
gives  a  reduction  of  32  millimètres,  equal  to  Iyô^^ô  ^"ch. 

After  having  enjoyed  pretty  good  health  for  about  two 
years,  he  was,  at  the  end  of  some  maneuvre,  suddenly  taken 
with  a  smart  pain  in  the  left  testicle  which  swelled  and  obliged 
him  to  go  to  the  hospital  of  the  guards,  where  he  was  admitted 
during  the  latter  part  of  April  1826.  The  inflammatory  ap- 
pearance of  this  organ  had  induced  the  medical  officer  of  the 
regiment  to  believe  that  it  had  been  caused  by  the  suppression 
of  a  gonorrhoea.  Although  the  patient  protested  never  to  have 
been  affected  with  any  syphilitic  complaint  whatsoever,  yet 
he  was  confined  in  the  venereal  ward,  where  all  the  usual  re- 
medies were  employed  calculated  to  overcome  both  the  sup- 
posed syphilitic  cause  and  its  consequences. 

The  disorder  having  grown  worse,  and  the  swelling  of  the 
testicle  having  considerably  increased,  the  extirpation  of  this 
organ  was  considered  indispensable,  and  was  performed  accord- 
ingly by  one  of  my  colleagues.  Doctor  Poirson,  surgeon 
major  in  charge  of  that  department.  The  operation  was  not 
attended  by  any  remarkable  occurrence.     After  two  months 


216  Injuries  of  the  Cerebellum. 

nursing  he  rejoined  his  regiment,  apparently  again  in  the  en- 
joyment of  perfect  health,  and  continued  to  do  service  till  the 
month  of  November  of  the  same  year,  at  which  period  he  per- 
ceived that  the  other  testicle  presented  symptoms  of  diseased 
action  similar  to  those  he  had  observed  in  that  which  he  had 
lost.  He  immediately  returned  to  the  hospital  towards  the 
end  of  the  same  month,  and  was  transferred  this  time  to  the 
ward  appropriated  for  the  wounded.  We  employed,  without 
success,  all  the  remedies  best  suited  to  induce  resolution  of 
this  organ.  Every  thing  intimated  a  carcinomatous  vitiation, 
and  indicated  the  accession  of  a  slow  symptomatic  fever. 
Notwithstanding  our  unwillingness  to  deprive  him  also  of  this 
last  organ,  we  deemed  it  necessary  to  extirpate  the  testicle, 
vi^hich  became  daily  more  and  more  a  source  of  infection  to 
the  patient,  already  much  exhausted.  We,  therefore,  per- 
formed this  second  castration,  which  was  not  attended  by 
any  unpleasant  symptoms,  and  he  recovered  in  the  space  of  a 
very  few  weeks:  but  one  remarkable  circumstance  is,  that  the 
nape  of  the  neck  has  been  sensibly  depressed  ever  since  the 
first  operation,  and  that  the  occipital  protuberance  of  the  side 
of  the  testicle  first  extirpated,  is  much  smaller  than  that  of  the 
opposite  side.  The  whole  frame  of  this  man  is  emaciated  ; 
his  beard  and  whiskers  are  almost  entirely  gone;  and,  in  fine, 
it  is  obvious  that  the  total  loss  of  the  genital  organs  has,  in  the 
full  sense  of  the  word,  exercised  a  marked  influence  upon  the 
cerebellum,  since  the  occipital  region  exhibits  in  this  man  a 
deep  and  abnormal  depression,  being  the  consequence  of 
atrophy  which  has  settled  alike  upon  all  the  bones  of  the 
cranium,  on  the  dermoid  tissue  of  the  face,  and  most  visibly 
upon  the  bulbous  roots  of  the  beard  which  has  disappeared. 
Thus,  this  soldier,  who  was  exhibited  before  the  Philomathic 
Society,  may  be  considered  as  a  highly  curious  subject,  be- 
cause of  the  remarkable  physiological  phenomena  which  in 
him  have  succeeded  one  another,  after  the  serious  disorders 
which  he  has  had  to  go  through.* 

*  The  sympalhelic  inflammalion  which  the  abstraction  of  the  geoital  organs 
coîïimuniciites  also  to  the  cerebellum  of  the  lower  animals,  is  very  evident  to 


Injuries  of  the  Cerebellum.  217 

In  concluding  the  account  of  the  diseases  and  injuries  of  the 
encephalon,  we  now  propose  to  treat  of  a  disease  which  we 
believe  to  be  seated  exclusively  in  this  organ, — I  allude  to 
nostalgia. 

ihe  anatomical  physician.  We  have  renaarked,  indeed,  in  comparing  the  crani- 
um of  these  animals  with  that  of  the  males  of  the  same  species  who  were  pro- 
vided with  those  organs  of  which  the  former  had  been  deprived,  that  the 
occipital  region  of  those  who  had  undergone  castration  declined  or  became 
depressed  by  degrees  to  such  an  extent,  that,  after  the  expiration  of  a  certain 
period,  the  cerebellum  of  this  class  of  animals,  all  circumstances  being  equal,  is 
reduced  to  a  much  smaller  volume  than  that  of  the  males  of  the  same  species 
which  have  been  permitted  to  keep  their  testicles.  Nay,  it  would  seem  that  the 
anterior  region  of  the  head  in  the  former  expands  in  the  same  ratio  of  the  reduc- 
tion which  takes  place  in  the  occipital  region.  This  phenomenon  may  be  ob- 
served in  capons,  for  example,  in  whom  the  cranium  assumes  the  shape  of  a 
helmet. 


2C 


OF  NOSTALGIA. 


Every  thing  proves,  in  opposition  to  the  opinion  of  some 
anatomists,  that  the  brain  or  the  encephalon  is  the  essential  or 
exclusive  vehicle  of  every  sensation,  whether  spontaneous  or 
conveyed  to  this  organ  from  without  by  some  external  agency. 
A  great  many  facts  relative  to  the  injuries  of  the  brain  which 
have  just  been  detailed,  and  numerous  autopsical  examina- 
tions which  we  have  made  within  the  last  forty  years,  have 
convinced  us  of  the  truth  of  this  assertion,  so  long  established 
by  the  highest  physiological  authorities,  Morgagni,  Haller, 
Vicq-d'Azyr,  Sœmmering,  and  Doctor  Gall. 

Indeed,  it  can  hardly  be  doubted  that  the  mental  affections, 
like  the  passions  of  the  soul,  have  their  exclusive  seat  within 
the  brain  ;  but  with  respect  to  nostalgia,  which  has  given 
origin  to  so  many  hypotheses  and  contradictory  opinions,  as 
to  its  seat  and  morbid  effects,  a  question  arises  whether  it  be 
seated  in  this  organ,  and  whether  it  changes  in  reality  the 
integrity  of  its  functions  ? 

This  is  a  very  grave  question,  which  I  shall  not  attempt 
to  decide;  I  shall  for  the  present  confine  myself  merely  to  re- 
late some  facts  respecting  this  genus  of  disease,  and  carefully 
describe  all  the  phenomena  which  accompany  or  characterise 
it,  and  the  differences  which  exist  or  may  exist  between  this 
morbid  affection  and  many  other  diseases  which  also  have 
their  seat  in  the  brain. 

It  is  very  evident  that  all  sensations  are  conveyed  to  this 
organ,  either  by  the  nervous  system,  with  which  it  is  in  im- 
mediate connexion,  or  by  the  senses  which  also  maintain  with 
it  an  intimate  and  direct  correspondence.     After  this  unex- 


Of  Nùstalgia.  219 

~; 

ceptionable  truth,  the  brain  must  necessarily  receive  the  first 
effects  of  these  sensations,  and  in  proportion  to  the  more  or 
less  decided  influence  which  those  effects  shall  produce  upon 
its  pulpy  substance,  will  be  the  relative  changes  in  the  inter- 
nal organs  which  directly  or  indirectly  derive  their  vital  pro- 
perties from  the  encephalic  nerves.  By  pursuing  this  nervous 
correspondence  a  little  further,  it  will  be  easy  to  arrive  at  an 
explanation  of  the  causes  of  certain  pathological  phenomena 
which  have  escaped  the  notice  of  the  observer. 

Thus,  the  first  effect  of  the  ardent  desire  which  he  who  is 
seized  with  nostalgia  feels  to  return  to  his  native  land,  must, 
if  it  cannot  be  satisfied,  necessarily  be  attended  by  a  painful 
anxiety  which  progressively  increases;  and  this  passion,  the 
result  of  the  emotions  transmitted  to  the  brain  by  the  senses, 
appears  first  of  all  to  affect  its  periphery,  where,  probably,  the 
organs  of  induction  reside. 

The  first  injurious  consequences  of  such  moral  impressions 
are  productive  undoubtedly  of  some  kind  of  expansion  of  the 
substances  of  the  brain,  of  the  engorgement  and  torpor  of  the 
vessels  of  this  organ,  and  successively  of  those  of  the  mem- 
branes which  envelope  and  line  its  cavities;  the  first  patholo- 
gical phenomena  which,  under  such  circumstances,  may  be 
observed,  are,  therefore,  an  impaired  condition  or  aberration 
of  the  intellectual  functions.  These  effects  afterwards  spread 
slowly  or  progressively  to  the  deep  seated  parts  of  the  brain 
which  furnish  the  organs  of  the  senses  and  of  locomotion  with 
nerves,  so  that  the  functions  of  these  organs  become  enfeebled 
also,  or  undergo  changes  which  are  marked  by  their  own  pe- 
culiar symptoms. 

Injuries  of  the  head,  or  any  other  external  causes  which  may 
infringe  the  integrity  of  the  brain  in  some  place  of  its  peri- 
phery, or  of  its  anterior  and  superior  surface,  are  apt  to  produce 
analogous  results.  In  cases  of  injuries  of  the  head,  which 
operate  in  an  inverted  ratio  from  the  interior  towards  the  sur- 
face (like  those  which  are  occasioned  by  mechanical  causes 
striking  in  an  oblique  direction  from  the  base  of  the  cranium 
towards  its  interior);  in  cases  of  metastases  which  transmit 
their  influence  from  some  point,  more  or  less  remote,  towards 


220  Of  Nostalgia. 

that  same  part;  and,  finally,  in  those  accumulated  fluid  secre- 
tions which  occur  in  the  cerebral  cavities,  the  alteration  of  the 
functions  of  the  brain  cannot  but  exhibit  a  difierent  career,  and 
be  attended  by  different  results.  Here,  however,  the  pressure 
bears  upon  the  origin  of  some  or  all  the  nerves  of  locomotion, 
upon  those  of  the  mixed  organs,  and  upon  those  of  the  senses, 
the  functions  of  which  are  soon  disturbed  and  impaired  in  a 
corresponding  degree,  while  the  intellectual  faculties  may  re- 
main unmolested  entirely  or  in  part;  for,  it  is  no  doubt  with 
these  faculties  as  with  those  of  the  organs  of  sense,  that  is  to 
say,  as  Doctor  Gall  maintains,  the  former  can  and  must  per- 
form their  functions  separately. 

I  shall  not  recapitulate  the  phenomena  or  the  symptoms 
which  are  ordinarily  occasioned  by  superficial  injuries  of  the 
cranium,  attended  with  fracture  and  with  direct  or  indirect 
lesion  of  the  brain;  they  have  been  described  already  in  the 
preceding  articles  and  observations.  However,  these  pheno- 
mena bear  a  great  analogy  to  those  which  I  am  about  to  detail 
in  this  essay. 

We  will  commence,  then,  with  a  statement  of  the  facts 
which  we  have  witnessed  in  a  great  many  nostalgic  patients, 
both  during  their  life  and  after  death.  In  them,  as  in  the 
majority  of  deranged  people,  the  mental  faculties  become  first 
affected,  and  the  functions  of  the  life  of  relation  undergo  suc- 
cessive changes  with  more  or  less  rapidity;  all  nostalgic  per- 
sons, in  fact,  are  subject  to  flights  of  the  imagination.  They 
think  they  perceive  from  afar  smiling  and  enchanting  pictures 
in  the  places  of  their  nativity,  however  sterile  and  uncultivated 
these  may  be;  their  parents  and  friends,  clad  in  rich  dresses  and 
evincing  the  most  affecting  emotions  of  joy,  come  on  purpose 
to  see  them.  The  first  moments  are  consequently  character- 
ised by  excitement,  which  is  manifested  by  a  spontaneous 
increase  of  heat  of  the  head,  by  a  greater  activity  of  the  pulse, 
by  restlessness  of  the  patient,  redness  of  the  conjunctivae,  un- 
steadiness of  the  eye,  precipitate  and  inaccurate  elocution; 
to  these  are  added  a  sense  of  oppression,  pandiculations,  sighs, 
constipation,  and  vague  pains  in  different  parts  of  the  body. 

This  state  of  pyrexia  will  be  succeeded  by  a  feeling  of  com- 


Of  Nostalgia.  221 

pression  and  restraint  pervading  every  organ.  The  stomach 
and  the  diaphragm,  receiving  no  longer,  as  in  the  healthy- 
state,  the  accustomed  stimulus  of  the  pneumo-gaslric  nerves, 
lapse  into  a  state  of  torpor,  manifesting,  forthwith,  symptoms 
of  gastric  derangement,  which  at  all  times  is  only  a  consecu- 
tive disorder  after  injuries  of  the  brain.  The  digestive  func- 
tions are  disturbed,  fever  grovvs  more  intense  and  travels  on 
with  its  usual  train  of  symptoms. 

In  the  third  stage,  asthenia  and  prostration  of  strength  are 
superadded;  the  patient  now  becomes  dejected,  he  sobs  and 
sheds  tears;  not  unfrequently  he  evinces  an  aversion  to  food 
and  occasionally  to  liquids  of  a  transparent  colour,  as  pure 
water  for  instance,  which  in  some  degree  imparts  to  him  an 
hydrophobic  character.  At  length,  life  becomes  a  burthen  to 
him;  and  in  this  state  he  inflicts  death  on  himself  without  any 
hesitation,  unless  the  hand  which  is  to  perform  the  act  have 
previously  been  seized  with  paralysis;  or  rather  his  vital 
powers  gradually  become  extinct,  when  he  expires  without 
knowing  himself. 

During  the  retreat  from  Moscow,  we  have  seen  a  great 
many  of  our  companions  perish  in  this  way,  whose  brain  had 
undergone  some  changes  in  the  same  direction,  in  conse- 
quence of  cold  of  from  25  to  28  degrees  (Reaumur). 

Autopsical  examinations  of  nostalgic  individuals  lead  to  the 
following  results  :  1.  The  surface  of  the  anterior  lobes  of  the 
brain  is  in  a  state  of  extensive  inflammation,  interspersed  with 
patches  of  suppuration,  the  seat  and  extent  of  which  are  vary- 
ing. The  arachnoid  and  pia  mater  participate  in  this  inflam- 
mation; the  substances  of  the  brain  are  hardened  and  their  arte- 
rial vessels  turgid  with  black  and  fluid  blood.  2.  The  lungs  also 
are  engorged;  the  cavities  of  the  heart  are  inordinately  dilated, 
and  filled  with  coagula  or  with  blood  of  a  blackish  aspect;  the 
stomach  and  the  intestines  are  distended  with  gas;  their  mu- 
cous membrane  is  injected,  yet  displays  no  symptom  of  actual 
inflammation.  Therefore  persons  will  not,  as  has  been  con- 
jectured, die  of  gastro-enteritis,  but  rather  of  the  eflects  of  the 
changes  of  structure  in  the  brain. 

From  our  remarks,  and  the  numerous  facts  which  we  have 


222  Of  Nostalgia. 

collected,  we  believe  that  premature  ossification  of  the  sutures 
of  the  bones  of  the  cranium,  as  well  as  of  the  arteries  of  the 
encephalon,  predisposes  to  nostalgia,  and  abridges  the  life  of 
the  individual  in  whom  these  phenomena  present  themselves. 
The  contrary  might  be  said  of  those  in  whom  this  kind  of 
ossification  is  retarded,  and  occurs  only  at  a  very  advanced 
age.  This  we  have,  at  least,  observed  in  the  heads  of  a  great 
many  old  people  of  upwards  of  seventy  or  eighty  years  of  age. 
Besides,  it  is  within  the  power  of  every  one  to  verify  the  cor- 
rectness of  these  assertions.  In  the  case  of  our  illustrious  as- 
sociate in  Egypt,  Monge,  whose  death  had  been  preceded  by 
profound  melancholy  and  intolerable  weariness  (ennui),  the 
cerebral  arteries  were  in  a  state  of  ossification.  This  worthy 
old  gentleman  who,  previously  to  the  commencement  of  the 
illness  of  which  he  eventually  died,  had  honoured  me  with  a 
visit,  shed  tears  of  sorrow  on  account  of  his  having  lost  his 
principal  patrons,  officers  and  titles.  Now,  there  is  no  doubt 
that  this  cause  had  largely  contributed  towards  the  spontane- 
ously diseased  process  of  the  ossification  of  his  cerebral  arteries. 

Similar  appearances  were  observed  in  the  brain  of  the  cele- 
brated Fourcroy,  whose  premature  death  had  been  accelerated 
by  the  same  causes,  by  profound  melancholy  and  disappoint- 
ment. 

We  shall  transcribe  here,  from  a  letter  of  one  of  his  asso- 
ciates, the  necropsy  of  Lord  Byron,  who,  at  an  early  age,  died 
in  Greece  of  a  fever  which  appeared  to  have  been  settled  in 
the  brain.*  1.  The  bones  of  the  head  presented  a  very  re- 
markable compactness;  the  cranium,  having  no  sutures,  re- 
sembled that  of  an  old  man  of  eighty  or  ninety  years  of  age; 
it  might  be  said  to  have  been  but  one  bone  without  any  inter- 
mediate diploe.  2.  The  dura  mater  adhered  closely  to  the 
internal  surface  of  the  cranium;  and  the  vessels  of  this  mem- 
brane were  injected  and  distended.  3.  Those  of  communica- 
tion between  it  and  the  pia  mater  were  filled  with  gas  and 
serum  of  a  whitish  appearance.  4.  The  parenchyma  of  the 
brain  was  intersected  by  many  vessels  containing  black  blood; 

*  The  extract  of  this  letter  was  given  to  me  by  the  Baron  Piiymaurin,  a  mem- 
ber of  the  Chamber  of  Depulies. 


Of  Nostalgia.  223 

the  lateral  ventricles  were  filled  with  limpid  serum;  the  other 
ventricles  and  the  spinal  canal  also  contained  a  good  deal  of 
fluid  of  the  same  character.  5.  The  medullary  substance  ex- 
tended beyond  its  ordinary  limits  into  the  midst  of  the  corti- 
cal substance,  the  thickness  of  which  was  much  reduced  in  a 
corresponding  proportion.  6.  The  convolutions  of  the  brain 
appeared  to  have  been  more  numerous  than  common,  and  the 
fissures  of  separation  very  deep.  (I  have  also  had  occasion  to 
notice  the  same  phenomenon  in  the  brain  of  other  illustrious 
personages.)  7.  The  whole  volume  of  the  brain,  as  far  as  the 
spinal  marrow  exclusive,  when  stripped  of  its  membranes, 
weighed  about  six  pounds  (eight  nuncps  weight,  poidsde  marc). 
In  other  respects  the  autopsy  of  this  great  man  presented 
nothing  particular,  unless  perhaps  a  slight  hypertrophia  of  the 
heart,  and  an  accumulation  of  dry  fœcal  matter,  which  implies 
an  obstinate  constipation,  to  which  this  lord,  indeed,  is  said  to 
have  been  subject  all  his  life. 

We  may  conclude  from  what  the  author  of  this  autopsical 
narrative  reports,  that  this  poet  could  not  have  lived  many 
years  more,  considering  the  pathological  condition  of  his 
cranium,  the  permanent  irritation  to  which  his  brain  seems 
always  to  have  been  exposed,  as  well  as  the  obstinate  constipa- 
tion which  doubtless  was  one  of  its  consequences,  and  which 
made  him  wish  for  his  death,  since  he  never  knew  how  to 
make  the  least  exertion  to  extricate  himself  from  this  com- 
plaint. Nor  would  he,  during  his  last  illness,  permit  any  one 
to  abstract  even  the  smallest  quantity  of  blood  from  him.  In 
fact,  this  last  assertion  has  found  its  way  into  the  public  prints. 
Byron,  therefore,  fell  a  victim  to  extreme  melancholy,  which, 
so  far  from  disposing  him  to  avoid  the  causes  tending  to  sever 
the  relations  of  life,  determined  him,  on  the  contrary,  to  seek 
them  with  some  degree  of  avidity. 

At  all  events,  I  hope  that  the  short  remarks  which  I  indulge 
in  deducing  from  these  facts,  may  incline  medical  men  to  in- 
stitute new  inquiries  into  the  nature  and  career  of  cerebral 
diseases,  the  anomalies  of  which  are  perhaps  more  numerous 
than  is  generally  believed. 

The  inhabitants  of  cold  and  moist  countries,  as  Holland  for 


224  Of  Nostalgia. 

instance,  or  of  mountainous  districts,  like  Switzerland  and 
Brisgaw,  are  more  liable  to  moral  impressions  producing  nos- 
talgia, a  remark  which  has  been  already  made  by  several  cele- 
brated physicians.  Thus,  the  troops  chiefly  of  these  nations, 
by  virtue  of  this  moral  conformation,  and  of  their  generally 
lymphatic  constitution,  suffered  most  from  the  dire  vicissitudes 
which,  during  the  campaign  of  Moscow,  we  had  been  doomed 
to  undergo;  whereas  on  the  burning  soil  of  the  ancient  world 
(the  opinion  of  certain  writers  who  have  never  visited  these 
regions  to  the  contrary  notwithstanding),  I  have  never  in  one 
single  instance  observed  the  least  symptom  of  nostalgia.  They 
all  had  formed  so  correct  and  favourable  an  idea  of  Egypt,* 
that  they  considered  her  like  their  second  country;  there  were, 
indeed,  few  of  our  companions  who  did  not  sincerely  regret 
this  climate. 

Several  Swiss  of  the  royal  guard  have  been  sent  in  success- 
ion to  the  hospital  for  the  purpose  of  being  cured  of  certain 
undefined  affections  which  very  soon  assumed  the  character  of 
nostalgia.  This  was  more  especially  remarked  in  1820,  and 
still  more  so  during  the  extreme  rise  of  the  barometer.  All 
mental  diseases  are  liable  to  grow  exasperated  under  such  cir- 
cumstances, of  which  I  possess  unequivocal  proofs.  The  first 
and  the  most  remarkable  case  of  this  kind  was  a  soldier  of  the 
first  Swiss  regiment,  about  30  years  of  age.  He  was  at  first 
admitted  into  the  fever  ward,  where  his  situation  displayed  to 
his  physician  Doctor  Cornac  no  symptom  of  an  alarming  na- 
ture, who  nevertheless  administered  to  him  every  possible 
comfort.  One  day,  while  visiting  the  hospital,  I  was  informed 
that  this  unhappy  man  had  just  attempted  to  commit  suicide, 
a  few  moments  after  being  visited  by  his  physician.  I  imme- 
diately hastened  to  his  assistance,  and  found  him  actually  bathed 
in  his  own  blood  and  almost  expiring,  in  consequence  of  a  large 
wound  which  he  had  inflicted  on  himself  in  the  praecordial  re- 
gion by  means  of  a  knife,  called  an  eustache  (claspknife).  The 
wound  was  situated  immediately  below  the  left  papilla,  and 
extended  obliquely  from  behind  forwards  about  three  inches 

*  See  the  Campaigns  in  Egypt  and  Russia,  vol.  i.  and  iv.  of  my  Memoirs. 


Of  Nostalgia.  825 

in  lengtli  by  pursuing  the  direction  of  the  space  between  the 
sixth  and  seventh  ribs.     There  were  some  muscles  divided,  and 
the  instrument  had  penetrated  into  the  chest  through  the  in- 
tercostal space.     A  very  large  quantity  of  blood  of  a  vermilion 
and  frothy  aspect  had  issued  and  continued  to  issue  from  the 
wound,  which  made  me  suspect  the  existence  of  a  deep  seated 
injury  of  the  lung  and  even  of  the  pericardium.     The  lips  of 
the  patient  were  discoloured,  his  eyes  fixed,  watery  and  half 
closed;  the  pulse  was  almost  gone  and  his  voice  entirelyextinct; 
the  extremities  were  cold  and  respiration  nearly  suppressed. 
I  found  to  my  great  surprise  on  the  edges  of  this  wound  seven 
different  incisions  which  divided  the  substance  into  as  many 
irregular  and  parallel  strips  of  two  or  three  lines  breadth.     It 
was  proved  also  that  the  patient  had  repeated  his  operation 
eight  or  nine  times,  and  no  doubt  until  his  strength  had  become 
exhausted  by  the  loss  of  blood  proceeding  from  the  injury  of  the 
lung.     If  the  patients  in  the  ward  and  the  nurses  had  not  been 
apprised  by  the  plaintive  scream  which  he  uttered  at  the  last 
stroke,  and  if  the  instrument  had  not  been  found  closely  locked 
in  his  rio-ht  hand,  the  medical  jurist  would  not  have  believed  that 
such  an  act  could  have  been  the  result  of  the  intuitive  strength 
of  the  individual.*     I  will  attempt  to  give  some  explanation  of 
this  phenomenon  at  the  end  of  the  case.     Notwithstanding  the 
desperate  situation  of  the  patient,  I  hastened   to  remove  the 
lacerated  strips,  and  to  simplify  the  wound  as  much  as  possible, 
in  order  to  bring  about  a  reunion  and  to  prevent,  of  course,  the 
passage  of  the  external  air.     Although  the  result  was  imper- 
fect  I,  nevertheless,  succeeded  in  suspending  the  fatal  career 
of  the  unfortunate  man,   and  recalled  him  to  some  degree 
of  life,  which  encouraged  me  to  conceive  some  hope  for  his 
welfare. 
The  development  of  the  pulse,  the  return  of  heat,  motion, 

•  During  my  education  at  the  general  hospital  of  Toulouse  I  remember  that  a 
lunatic,  having  secreted  a  razor  under  the  straw  of  his  bed,  gave  himself  five  or 
six  incisions  in  the  abdomen,  nearly  all  in  a  line.  One  of  them  having  penetrated 
into  its  cavity  to  the  extent  of  two  or  three  inches,  caused  a  protrusion  of  almost 
all  the  viscera,  and  the  patient  perished  the  sooner  as  he  himself  pulled  off  a  part 
of  his  intestines. 

2D 


226  Of  Nostalgia. 

respiration  and  of  the  colour  of  the  lips,  announced  the  ces- 
sation of  the  internal  hemorrhage  and  the  reaction  of  the  vital 
powers.  I  directed  embrocations  of  hot  and  camphorated  oil 
of  chamomile  to  be  made  to  the  extremities  and  abdomen,  and 
antispasmodics,  mucilaginous  draughts  and  sweetened  emulsions 
to  be  given  internally.  I  ordered  the  application  of  ice  to  the 
head,  and  endeavoured  to  soothe  the  mind  of  the  patient  by- 
promising  him  a  furlough  to  return  to  his  country,  if  such  was 
his  wish;  but  he  paid  not  the  slightest  attention  to  these  pro- 
posals, which  his  state  of  mental  derangement  would  not  permit 
him  to  appreciate.  He  had  sunk,  moreover,  into  such  an  ab- 
solute physical  apathy  as  not  to  evince  the  least  degree  of  pain 
during  the  operation  made  at  the  moment  when  he  was  being 
dressed  for  the  first  time,  and  seemed  to  give  himself  up  uncon- 
ditionally to  the  fate  which  awaited  him.  At  last  he  expressed 
no  longer  a  desire  for  any  thing,  every  function  of  the  life  of 
relation  being  greatly  enfeebled,  and  those  of  the  internal 
organs  in  a  perturbed  condition.  Notwithstanding  this  he 
enjoyed  pretty  good  rest  for  several  hours,  uninterrupted  by 
the  slightest  unfavourable  symptom.  But,  the  patient  having 
torn  off  the  dressing  during  the  night,  symptoms  of  traumatic 
inflammation  became  manifest  the  next  day  and  travelled  with 
extreme  rapidity.  All  the  remedies  usually  indicated  in  such 
cases  were  insufficient,  and  he  died  in  the  most  dreadful  agony 
on  the  fifth  or  sixth  day  after  he  had  attempted  his -life. 

On  inspecting  the  body  twenty-four  hours  after  death,  I 
found  the  wound,  as  I  had  intimated  before,  penetrating 
into  the  left  cavity  of  the  thorax,  through  the  intercostal 
space  between  the  sixth  and  seventh  rib:  the  blade  of  the 
instrument  had  in  the  first  place  pierced  a  part  of  the  lung, 
after  which  it  had  grazed  the  pericardium  and  lacerated  the 
phrenic  nerve  of  the  left  side.  There  were  about  two  pounds 
of  blood  and  serum  effused  into  this  cavity.  All  the  serous 
membranes  were  inflamed  and  covered  with  a  layer  of  albu- 
men, in  which  bloodvessels  were  ramifying  already  for  the 
purposes  of  inosculation.  The  lung  was  divided  about  one  inch 
deep  and  the  remainder  of  it  was  hepatized.  The  cavities  of 
the  heart  were  much  dilated  and  filled  with  black  and  liquid 


Of  Nostalgia.  227 

blood.  The  right  lung  and  the  abdominal  viscera  were 
healthy.  On  opening  the  cranium,  the  sutures  of  which  were 
almost  completely  effaced,  we  found  a  layer  of  purulent  albu- 
men which  covered  the  whole  periphery  of  the  brain  and 
involved  besides  the  arachnoid  membrane.  There  might  be 
perceived,  also,  several  suppurated  spots  in  the  cortical  sub- 
stance of  this  organ,  especially  about  the  anterior  lobes  and 
superior  margin  of  the  hemispheres.  The  sinuses  of  the  dura 
mater  and  all  the  blood  vessels  of  the  encephalon  were  engor- 
ged with  black  and  carbonized  blood:  the  ventricles  contained 
a  pretty  large  quantity  of  serum,  but  the  base  of  the  brain  and 
cerebellum  was  healthy. 

It  may  be  inferred  from  these  facts  that  the  cephalitis  which 
had  been  developed  gradually  under  the  influence  of  the  pro- 
found moral  affection,  which  had  been  occasioned,  in  this  Swiss 
soldier,  by  the  ardent  desire  to  return  to  his  native  land,  must 
have  preceded  the  attempt  at  suicide,  which  in  itself  may  be 
looked  upon  rather  as  an  automatic  act,  independent  of  the  will 
of  the  individual.  I  shall  endeavour  to  explain  this  singular 
phenomenon. 

I  have  already  remarked  that  the  animal  sensibility  of  this 
nostalgic  patient  had  been  nearly  extinct  at  the  time  of  the 
wounds  which  he  had  inflicted  upon  himself,  for  he  evinced 
not  the  slightest  symptom  of  pain  while  the  incisions  were  made, 
in  order  to  dilate  the  corners  of  the  wound  and  to  cut  off  the 
irregular  flaps  of  the  integuments  of  which  I  have  spoken 
above.  Unless  this  sensibility  had  been  extinct  from  the  com- 
mencement of  the  disease,  he  could  never  have  repeated  as 
often  as  eight  times  the  painful  and  difficult  operation  which 
he  performed  on  himself  with  a  very  bad  knife.  Yet,  how  shall 
we  account  for  the  cause  which  set  the  muscular  power  in  mo- 
tion to  impel  the  hand  of  the  unfortunate  man  with  so  much 
strength,  while  his  sensibility  was  almost  gone  and  his  intel- 
lectual faculties  were  in  such  a  state  of  aberration  and  weakness 
that  to  the  questions  put  to  him  he  replied  only  by  monosylla- 
bles entirely  foreign  to  the  subject  ?  1.  This,  as  well  as  other 
facts  analogous  to  it  which  will  be  related  in  the  sequel  of  this 
memoir,  appear  to  me  to  demonstrate  that  the  nervous  cords 


22^  Q/^  Nostalgia. 

which  produce  the  sensibility  of  relation  and  those  which  are 
subservient  to  the  functions  of  locomotion  have  a  distinct  origin 
in  the  brain   or  in  its  prolongations,  which  renders  the  hypo- 
thesis probable  which   I  have  stated,  when  speaking  of  the 
nerves  of  animal  life,*  on  the  occasion  of  the  electric  telegraph 
of  the   celebrated  Soemmering.     2.   The  consecutive  pheno- 
mena exhibited  in  this  Swiss  soldier  are  equally  in  favour  of 
the  theory  of  Doctor  Gall  on  the  seat  of  the  organs  which  are 
subservient  to  the  intellectual  faculties.     This  celebrated  ana- 
tomist places  these  organs  in  the  convolutions  occupying  the 
surface  of  the  superior  and  anterior  half  of  the  cerebral  hemis- 
pheres.    Persons  with   dropsy   of  the   ventricles,    or   other 
spontaneous  congestions  making  an  anomalous  compression  on 
one  or  more  places  of  the  base  of  the  brain,  so  as  to  produce 
total  or  partial  paralysis  of  the  organs  of  locomotion  without 
affecting  their  intellect,  furnish  still  more  proofs  in  support  of 
this  opinion.     For  the  further  confirmation  of  these  remarks 
I  shall  now  proceed  in  laying  before  the  reader  the  result  of 
my  investigations  in  those  individuals  who  have  been   treated 
under  my  own  eyes. 

John  Humbert,  a  guardsman  of  the  5th  regirhent  of  infantry, 
entered  the  hospital  in  August  1820,  on  account  of  a  slight 
contusion  of  the  chest  which  he  had  received  in  consequence 
of  a  fall.  He  had  scarcely  recovered  from  the  effects  of  this 
accident,  when  he  evinced  a  very  strong  desire  to  go  to  his  na- 
tive province  (one  of  the  valleys  of  Franche  Comté):  1  forthwith 
directed  a  convalescent  pass  to  be  made  out  for  him,  and  pro- 
mised him  that  he  might  depart  as  soon  as  it  should  be  returned 
from  the  war  department;  at  the  same  time  1  prescribed  a  mild 
regimen  and  pediluvia.  Notwithstanding  these  precautions, 
symptoms  of  nostalgia  suddenly  made  their  appearance  and  be- 
came developed  with  extreme  rapidity.  The  barometer  stood 
at  that  period  at  twenty-eight  inches  and  several  lines. 

The,  first  apparent  symptoms  in  this  young  soldier  were 
signs  of  mental  aberration  and  pain  in  the  head.     He  spoke 

*  We  shall  re-insert  this  memoir  of  ours  on  the  origin  of  these  nerVes  at  the 
end  of  the  article  on  the  injuries  of  the  head. 


Of  Nostalgia.  229 

little,  liis  ideas  were  incoherent,  and  during  nearly  the  whole 
night  he  was  in  a  state  of  somnambulism.  Notwithstanding 
the  cephalalgia  of  which  he  at  first  complained,  he  had  no  other 
pain  besides;  yet  he  pressed  his  hand  habitually  on  the  forehead; 
he  was  restless  and  in  a  continual  state  of  insomnia;  the  extre- 
mities were  always  cold  and  his  pulse  slow  and  irregular.  An 
unnatural  heat  could  be  perceived  on  the  vertex,  the  vessels  of 
the  conjunctiva  were  injected,  the  eyes  watery,  and  his  looks 
unsteady.  He  ate  nothing  and  evinced  a  very  great  repug- 
nance to  use  clear  drinks,  such  as  pure  water,  but  enjoyed  in 
some  degree  coloured  and  bitter  decoctions.  This  state  of 
exacerbation  was  soon  followed  by  some  kind  of  general 
collapse.  The  powers  of  locomotion  declined  progressively 
to  such  an  extent  that  the  patient  could  no  longer  raise  himself 
up  in  bed;  his  sensitive  functions  became  reduced  also  in  the 
same  proportion;  and  finally,  he  fell  into  a  state  of  lethargy, 
during  which  he  answered  none  of  the  questions  addressed  to 
him,  while  his  physical  sensibility  was  almost  altogether  ex- 
tinct. I  employed  at  first  but  few  curative  remedies,  but 
seeing  that  the  disease  began  to  assume  a  serious  character,  I 
decided  upon  opening  the  jugular  vein  and  subsequently  also 
the  temporal  artery,  and  directed  sinapisms  to  be  applied  to 
the  feet,  ice  to  the  head  and  dry  and  scarified  cups  to  the  hy- 
pochondriac and  abdominal  regions,  besides  which  antispas- 
modic mucilaginous  drinks,  emollient  anodyne  enemata  and 
camphorated  oily  embrocations  were  prescribed.  The  result 
of  this  treatment  was  a  temporary  calm;  but  the  cerebral  affec- 
tion became  again  developed,  and  travelled  so  rapidly,  that  the 
stimulus  conveyed  by  the  pneumo-gastric  nerves  to  the 
stomach,  the  lungs,  and  no  doubt  also  to  the  heart,  was  there 
annihilated;  the  functions  of  these  organs  were  in  consequence 
greatly  impaired  by  some  kind  of  paralytic  affection  or  stupor, 
which  occasioned  the  engorgement  of  their  membranes,  as 
well  as  all  the  characteristics  of  phlegmasia  peculiar  to  each  of 
these  viscera. 

Such  is  ordinarily  the  origin  of  angina  pulmonalis,  gastritis 
and  enteritis,  which,  according  to  their  concomitant  causes, 
become  developed  with  more  or  less  facility;  but  they  are  the 


230  Of  Nostalgia. 

result  of  disease  of  the  brain.  To  return  to  my  subject,  he 
fell  into  a  state  of  complete  ataxia,  and  expired,  apparently 
without  any  pain  whatever,  in  the  night  of  the  ninth  to  the 
tenth  day  after  the  appearance  of  the  first  symptoms. 

On  inspecting  the  body  twenty-four  hours  after  death,  I 
perceived,  as  in  the  subject  of  the  first  obsei'vation,  the  whole 
intestinal  tube  considerably  distended  with  gas,  and  the  mucous 
membranes  of  the  stomach  and  intestines  injected,  yet  without 
symptoms  of  inflammation.  The  liver  of  a  brownish  colour 
was  much  engorged  and  stretched  beyond  the  margin  of  the 
false  ribs. 

On  opening  the  cranium  and  vertebral  canal  I  discovered  a 
layer  of  albumen  covering  the  whole  periphery  of  the  hemis- 
pheres of  the  brain;  it  was  situated  between  the  dura  mater  and 
the  pia  mater;  patches  of  suppuration  of  a  yellowish  aspectpene- 
trated  pretty  far  into  the  anterior  lobes  of  this  organ,  and  a 
pretty  large  quantity  of  reddish  serum  was  contained  in  the 
lateral  ventricles.  The  different  substances  of  which  the  en- 
cephalon  is  composed  were  thickened,  and  the  spinal  mem- 
branes in  a  phlogose  condition. 

A  third  soldier  who  died  of  the  same  disease  and  at  the 
same  time,  in  the  fever  wards  of  the  hospital,  presented  the 
same  phenomena  before  and  after  death. 

The  subject  of  the  following  observation  has  during  his 
illness  and  after  death  displayed  remarkable  peculiarities. 
Francis  D.,  a  private  of  one  of  the  regiments  of  the  guards, 
aged  23  years,  born  in  the  department  Du  Nord,  on  the  fron- 
tiers of  Belgium,  fair  and  of  lymphatic  temperament,  was  ad- 
mitted into  the  wards  of  the  wounded  of  the  hospital  of  Gros 
Caillou,  towards  the  end  of  February  1820,  on  account  of  some 
pain  in  the  left  shoulder,  accompanied  by  numbness  and  stiffness 
in  the  arm  of  the  same  side.  He  evinced  an  extreme  repug- 
nance to  the  military  profession,  and  expressed  to  his  comrades 
his  desire  to  return  to  his  native  province.  Combined  with 
these  particular  circumstances  were  all  the  symptoms  of  an 
exhaustion  of  his  moral  and  physical  powers,  which  was  the 
gloomy  result  of  onanism,  to  which,  by  his  own  confession, 
this  young  man  had  been  given  without  restraint.     I  ordered 


Of  Nostalgia.  231 

the  successive  application  of  scarified  cups  and  of  several  Chi- 
nese moxas  to  the  parts  affected,  whereby  the  pains  were 
appeased  and  the  motions  of  the  arm  restored.  The  patient, 
at  length,  considering  himself  cured,  left  the  hospital  and  re- 
turned to  his  regiment.  I,  nevertheless,  took  the  precaution 
to  recommend  him  to  his  surgeon-major,  on  account  both  of 
his  moral  condition  and  of  the  afiection  for  which  he  had  en- 
tered the  hospital,  and  which  was  by  no  means  yet  entirely 
removed. 

In  this  situation  he  remained  for  several  days,  but  another 
disease  became  established,  and  on  the  1st  of  April  following 
he  was  again  brought  into  the  hospital  and  lodged  in  the  fever 
ward.  He  manifested  all  the  symptoms  of  a  febrile  afiection 
of  the  brain,  and  though  he  was  already  deprived  of  his  reason 
and  of  almost  all  his  sensitive  faculties,  yet  he  evinced  the 
most  unequivocal  signs  of  nostalgia,  for  during  the  delirium 
with  which  he  had  been  attacked,  he  incessantly  talked  about 
his  country.*  Rubefacients  were  applied  to  the  feet  and  legs, 
and  every  other  remedy  indicated  in  such  cases,  was  employed. 
The  slight  delirium  which  he  had  displayed  at  first,  was  suc- 
ceeded presently  by  lethargic  drowsiness  which  continued 
increasing  to  the  period  of  his  death;  all  the  animal  and  sen- 
sitive functions  declined  rapidly,  and  the  patient  sunk  into  a 
state  of  absolute  prostration;  his  limbs  were  palsied,  his  hands 
were  crossed  over  the  abdomen  and  his  eyes  shut.  Such  was 
his  situation,  when  I  was  desired  to  visit  him  in  the  fever 
ward;  the  disease  was  then  of  six  days  standing.  Loud  calls, 
slight  shocks  and  shakings  were  alike  insufiicient  to  rouse 
him  from  this  state  of  lethargy.  The  eye-lids,  when  separated 
with  the  finger,  exhibited  the  eyes  fixed,  dull  and  inanimate; 
the  pupils  were  dilated,  and  the  rays  of  the  sun,  as  well  as 
slight  frictions  over  the  eye-lids,  made  no  impression  whatever 
upon  them.  Desirous  to  ascertain  the  state  of  animal  sensi- 
bility, which  I  had  reason  to  believe  entirely  extinct,  I  applied 

•  The  exciting  causes  of  this  disease  couid  not  be  ascertained.  It  is  not 
unlikely  that  the  patient  may  have  tried  to  drown  his  disappointment  and  weak- 
ness by  means  of  spirituous  liquors,  in  the  use  of  which  all  soldiers,  especially  at 
Paris,  are  in  the  habit  of  indulging  themselves. 


2 33  Of  Nostalgia. 

lighted  matches  to  different  parts  of  the  body.  These  repeated 
burns  produced  not  the  least  sensation  in  D.,  nor  could  I 
perceive  the  slightest  motion  in  any  of  the  burnt  parts;  the 
beatings  of  the  heart  and  the  pulse  which  was  vermicular  and 
barely  perceptible,  experienced  no  further  change. 

With  the  intention  to  make  a  decided  impression  upon  the 
solar  plexus,  I  placed  some  dry  cups  over  the  epigastrium. 
To  my  great  surprise  they  produced  a  simultaneous  action  of 
elevation  in  the  upper  eye-lids,  of  contraction  of  the  iris  of 
both  sides,  and  of  circumduction  in  the  ball  of  the  eyes. 
These  motions  I  caused  to  be  repeated  at  will  several  times  by 
the  same  means;  and  they  convinced  me  still  more  that  the 
consciousness  of  this  individual  could  no  longer  appreciate  any 
of  these  sensations,  and  that  his  vision  was  gone,  for  he  showed 
not  the  least  mark  of  pain  during  the  application  of  the  burn- 
ing match  or  of  the  cups,  heated  as  they  were  by  spirits  of  wine 
set  on  fire.  The  same  application  to  the  extremities  did  not 
produce  any  visible  impression,  whilst  its  repetition  on  the 
epigastrium  a  second  time  induced  a  sensible  contraction, 
particularly  in  the  iris  of  both  sides,  which  continued  even, 
after  death,  for  on  examining  the  corpse,  the  pupils  were  still 
contracted. 

At  length,  after  an  interval  of  a  purely  vegetating  existence, 
and  after  a  condition  of  almost  complete  dissolution,  the  last 
breath  of  life,  which  had  intrenched  itself,  as  it  were,  in  the 
internal  organs,  fled,  and  the  patient  expired  on  the  seventh 
day  from  the  commencement  of  his  illness.  Thirty -six  hours 
after  death  I  examined  his  body,  by  beginning  with  the 
splanchnic  cavities.  I  found  the  abdomen  and  the  serous 
covering  of  the  small  intestines,  that  of  the  ileum  in  particular, 
in  a  state  of  chronic  inflammatory  engorgement;  small  whitish 
granulations  and  points  of  adhesion  between  the  intestinal  con- 
volutions were  visible  upon  them;  the  mucous  membrane  of 
the  alimentary  canal  was  white  throughout  its  whole  extent; 
the  bladder  was  filled  with  urine  of  a  dark  red;  the  liver  and 
the  spleen  were  turgid  with  black  and  fluid  blood.  The  lungs 
were  healthy;  the  two  laminae  of  the  pleura  adhered  to  each 


Of  Noalalgia.  233 

other  by  membranous  filaments  of  old  formation;  the  heart 
and  its  dependencies  were  in  the  usual  condition. 

The  scull-cap,  being  sawed  and  removed,  appeared  to  me, 
considering  the  proportions  of  the  subject,  to  present  an  extra- 
ordinary and  unnatural  excavation.  The  sutures,  digitations 
and  furrows  usually  to  be  observed  there,  were  entirely  effaced, 
and  the  bones  of  this  as  well  as  of  every  part  of  the  scull  were 
greatly  diminished  in  thickness.  The  dura  mater  presented 
no  morbid  appearance,  but,  after  having  made  an  incision  into 
it  and  divided  its  folds,  I  found  the  arachnoid  membrane 
covered  with  purulent  albuminous  patches,  some  of  which 
penetrated  through  the  pia  mater  into  the  brain  itself;  they 
were  more  especially  perceptible  on  the  internal  margins  of  the 
hemispheres  and  along  the  whole  superior  surface  of  the  ante- 
rior lobes.  A  deposition  of  purulent  matter  existed  at  the 
base  of  the  left  lobe  of  the  cerebellum,  which  was  by  one-sixth 
larger  than  the  right.  The  lateral  ventricles  contained  a 
pretty  large  quantity  of  serum,  which  even  spread  into  the 
spinal  canal.  The  whole  substance  of  the  brain  was  in  a  state 
of  expansion  and  compactness  far  more  decidedly  marked  than 
is  ordinarily  observed  in  inflammations  of  this  organ.  The 
expansion  of  the  encephalon  had  attained  to  such  a  degree  that 
from  its  periphery  it  protruded  into  all  the  cavities  of  the  cra- 
nium, while  it  was  depressed  in  all  the  projecting  places  of 
the  scull.  Thus,  for  example,  the  anterior  extremities  of  both 
hemispheres  were  flattened  and  depressed  upon  the  eminences 
formed  by  the  orbits,  so  as  to  present  a  slope  of  a  depth  and 
shape  corresponding  to  these  bony  projections,  while  the  in- 
ternal margins  of  both  these  lobes  had  sunk  into  both  ethmoidal 
fossae,  being  separated  by  the  crista  galli. 

This  post  mortem  examination  furnishes  an  incontestable 
proof  that  in  nostalgia,  as  well  as  during  a  state  of  exaltation 
of  all  the  sombre  affections  of  the  soul,  the  brain  in  reality 
undergoes,  as  I  have  already  observed  in  the  progress  of  this 
article,  an  actual  expansion,  or  abnormal  exuberance,  which  is 
the  result  of  the  erectility  of  its  substances,  occasioned  by 
onanism,  and,  generally  speaking,  by  every  other  cause  of  ex- 
2  E 


234  Of  Nostalgia. 

citement.*  There  is,  therefore,  some  truth  hi  the  remark  oi 
those  who  are  attacked  by  this  disease  when  they  say  that  their 
scull  is  ready  to  burst. 

I  believe  that  I  have  saved  several  nostalgic  patients  by  the 
exhibition  of  the  remedies  above  indicated,  and  administered 
according  to  the  modifications  suggested  by  the  idiosyncrasy 
of  the  individual  and  by  the  duration  of  the  disease:  steady 
exercise,  but  especially  the  instantaneous  departure  of  the  pa- 
tients for  the  country  to  which  they  long  to  return,  greatly 
promote  their  recovery.  Vigarous,  a  professor  of  Montpellier, 
cured  all  the  English  who  came  to  consult  him  for  the  spleen, 
by  directing  them  to  make  long  and  uninterrupted  excursions 
on  foot,  on  horseback,  or  by  travelling  post,  according  to 
their  circumstances.  In  addition  to  which  he  prescribed  for 
them  some  harmless  mixtures,  variously  coloured,  under  the 
pretext  of  their  being  compound  medicines  and  of  a  high  price. 
Journeys  to  watering  places  in  picturesque  situations  have 
been  recommended  by  the  older  physicians,  as  well  as  by  those 
of  our  own  times,  for  the  purpose  of  dissipating  melancholy 
and  preventing  nostalgia. 

A  lymphatic  idiosyncrasy  already  alluded  to,  an  unaccus- 
tomed sojourn  in  cold  and  moist  climates,  slavery  or  impri- 
sonment,t  indolence,  excess  in  venery  or  onanism  are,  gen- 
erally speaking,  the  causes  of  nostalgia  and  of  every  other 
species  of  melancholy  insanity,  the  effects  of  which  centre  in 
the  brain.  The  periods  of  the  sudden  rise  of  the  barometer 
have  appeared  to  us  best  calculated  for  the  development  of 

•  A  similar  phenomenon  may  be  observed  in  cases  of  hernia  cerebri^  which 
occasionally  occur  through  the  openings  made  into  the  cranium  during  the  opera- 
tion of  trepanning.  This  might  be  called  spontaneous  acute  cerebritis  in  the 
first  case,  and  accidental  cerebritis  in  the  second.  This  affection  is  analogous 
to  enteritis  which,  in  the  instance  of  hernia,  happens  in  the  strangulated  portion 
of  the  intestine. 

■f  It  is  more  especially  owing  to  confinement  in  prisons  that  nostalgia  and  so 
many  other  mental  diseases  derive  their  origin.  All  the  prisoners  should  be 
compelled  to  do  some  kind  of  work,  for  whicli  they  should  be  compensated  (as 
is  done  in  the  United  States).  From  this  proceeding  the  double  advantage 
would  arise  to  improve  their  manners  and  to  obviate  the  effects  of  a  mischievous 
idleness. 


Of  Nustalgia.  235 

these  diseases.  In  order  to  prevent  this  kind  of  cerebral 
affection,  particularly  in  those  soldiers  who  join  their  corps,  it 
will  be  necessary,  therefore,  to  indulge  these  individuals  thus 
predisposed  only  in  the  repose  necessary  for  the  reparation  of 
their  strength,  exhausted  during  tlie  day,  and  to  vary  their 
occupations,  by  turning  both  their  labours  and  their  recreations 
to  their  own  advantage  as  well  as  to  that  of  the  community. 
Thus,  after  the  customary  military  exercises,  it  would  be  well 
to  compel  them  to  go  through  a  course  of  gymnastics  and 
some  method  of  useful  instruction.  It  is  in  this  respect  parti- 
cularly that  mutual  instruction,  as  established  amongst  the 
troops  of  the  line,  proves  advantageous  to  the  soldiers  them- 
selves and  to  the  state  likewise.  Martial  music,  which  should 
be  made  during  meals  and  between  the  hours  of  recreation, 
would  contribute  considerably  to  enliven  the  spirits  of  the 
soldier  and  to  divert  the  moody  and  gloomy  reflections  to 
which  the  causes  above  enumerated  so  frequently  give  rise. 
By  means  of  these  precautions  and  the  application  of  the  above 
principles  of  hygiene,  I  have  had  the  good  fortune  to  preserve 
the  crew  of  our  frigate  from  nostalgia  and  every  other  serious 
disease,  during  the  tedious  cruise  which  I  made  in  the  Northern 
ocean  in  the  years  1787  and  1788,  in  which  we  lost  but  one 
man  in  consequence  of  the  hardships  of  a  shipwreck.  It 
should  be  the  business  of  the  paternal  solicitude  of  the  chief 
officers  of  each  army-corps,  assisted  by  the  advice  of  the 
surgeon  majors,  to  carry  into  effect  the  measures  above  men- 
tioned for  the  purpose  of  preventing  nostalgia,  a  disease  which 
is  the  more  serious  in  proportion  to  its  insidious  nature.  But, 
if  the  authorities  neglect  to  lay  the  talents  and  the  experience 
of  physicians  under  contribution,  it  will  still  be  the  duty  of 
the  latter  to  leave  nothing  untried  to  arrest  the  progress  of  this 
affection,  as  soon  as  it  may  appear,  by  obviating  its  effects, 
and  hastening  the  cure  of  the  patients. 

With  this  objectin  view,  and  in  the  instance  where  nostalgia 
has  positively  manifested  itself  in  an  individual,  I  shall  in  its 
course  point  out  the  mode  of  treatment  which  has  appeared  to 
me  to  be  the  most  judicious,  together  with  the  results  which  I 
have  derived  from  it. 


236 


Of  Nostalgia. 


During  the  first  stage,  which  is  that  of  pyrexia,  the  blood- 
vessels of  the  head  should  be  depleted  by  direct  and  derivative 
blood-lettings;  the  fluids  of  this  part  be  condensed  gradually 
by  ablutions  of  the  vertex  with  cold  water  or  with  ice,  accord- 
ing to  the  indication;  a  revulsion  be  induced  towards  the 
depending  parts,  and  the  development  of  the  functions  of  the 
internal  organs  be  promoted,  by  means  of  emollient  demi-baths, 
at  a  temperature  of  25  to  26  de,grees  (Reaumur),*  by  the  ap- 
plication of  cups  to  the  hypochondria,  epigastrium  and  dorsal 
regions,  to  be  followed  up  by  oleaginous  camphorated  embro- 
cations. In  addition  to  these,  diluents  and  antispasmodics  may 
be  exhibited  internally.  Gymnastics,  music  and  pretty  steady 
exercise  should  also  not  be  lost  sight  of. 

Whenever  the  disorder  shall  have  reached  the  second  stage, 
which  is  that  of  collapse,  the  strength  of  the  patient  must  be 
supported  by  mild  stomachics.  Dry  alkaline  frictions  are  to 
be  made  over  the  entire  surface  of  the  body;  the  application 
of  moxas,  or  of  slight  cauteries  about  the  base  of  the  cranium 
should  be  had  recourse  to.  The  patient  is  to  be  put  upon  the 
use  of  tea-like  infusions  of  cinchona,  cascarilla  and  canella. 
He  should  be  prevailed  upon  to  submit  to  a  change  of  climate, 
and  above  all,  as  much  as  may  be  practicable  to  exchange  a 
moist  and  cold  place  of  residence  for  a  warm  and  salubrious 
country. 

In  the  third  stage,  unless  nature  herself  can  induce  a  salu- 
tary crisis,  art  has  but  few  resources  left.  At  all  events, 
however,  the  nostalgic  patient  should,  during  the  whole  career 
of  this  dangerous  disease,  be  treated  with  much  gentleness  and 
suavity. 

In  proof  of  these  views,  and  in  order  to  render  them  yet 
more  intelligible,  I  propose  to  give  a  summary  of  the  cases  of 
several  individuals  whom  1  have  successfully  treated. 

The  first,  John  Barbier,  aged  25  years,  a  private  of  the  first 
regiment  of  cuirassiers  of  the  royal  guard,  had  received  a 
slight  contusion  of  the  head  and  exhibited  all  the  symptoms  of 
nostalgia,  a  few  days  after  being  admitted   into  the  hospital 


Equal  to  about  89  (o  91  degrees  of  Falircnlicit'ti  tlieimomelcr.     Tiansl 


0/  Nostalgia.  237 

(which  iiappened  in  the  mickllc  of  January  1820,  at  a  period 
when  the  barometer  had  suddenly  risen  from  27  inches  2  lines 
to  28  inches  4  lines).  From  what  I  could  collect  from  his 
comrades,  the  wish  which  this  soldier  had  entertained  for 
some  time  to  return  to  his  native  land,  and  the  recent  concuss- 
ion of  the  head,  may  be  considered  as  the  incidental  causes  of 
the  disease.  The  symptoms  rapidly  travelled  to  a  frightful 
height  and  the  patient  was  in  danger  for  several  days;  how- 
ever, under  the  influence  of  the  treatment,  a  sketch  of  which 
I  have  just  given,  these  were  quieted,  and  in  less  than  three 
weeks  he  had  recovered  and  was  in  fit  condition  to  resume 
his  military  duties;  he  would  not  even  make  use  of  a  furlough 
of  convalescence  which  I  had  caused  to  be  made  out  for  him. 
Blood-letting  from  the  jugular  vein,  scarified  cups  to  the  back, 
ice  to  the  head,  and  several  moxas  to  both  sides  of  the  nucha, 
have  appeared  to  me,  in  the  treatment  of  this  case,  to  be  the 
remedies  which  were  conducive  to  the  cure  of  the  patient. 

The  second,  Theophilus  Barbet,  aged  23  years,  was  sent  to 
the  hospital  on  the  Sth  of  January  of  the  same  year,  on  account 
of  a  fall  which  he  had  previously  experienced.  From  the  next 
dayafterhisadmissionhedisplayedsymptomsof  nostalgia.  His 
comrades  informed  me  that  during  the  whole  night  he  had 
walked  from  one  ward  into  another,  talking  incessantly  of  his 
country  and  of  his  parents.  In  fact,  I  discovered  in  this  man 
the  symptoms  of  an  incipient  affection  of  the  brain,  accompa- 
nied by  mental  alienation  and  by  disturbance  of  the  sensitive 
functions.  During  the  first  two  or  three  days  I  employed  but 
few  remedies;  I  had  been  persuaded  to  believe  that  a  furlough 
of  convalescence  which  I  had  promised  him,  would  quiet  him; 
but  the  symptoms  having  become  aggravated  since,  and  after 
having  employed  part  of  the  night  in  running  about  through 
several  wards,  he  cleared  the  walls  of  the  garden  and  disap- 
peared. He  endeavoured  to  gain  the  road  leading  to  his  native 
district,  when  he  was  met  by  some  soldiers  of  his  regiment, 
who  conducted  him  back  to  the  hospital,  January  15th,  at  the 
hour  of  my  visiting  tour.  He  was  restless  and  agitated;  an 
unnatural  heat  might  be  observed  on  some  part  of  the  head; 
liis  eyes  were  injected;  the  pulse  was  vibrating  and  scarcely 


238  Of  Nostalgia. 

returned  fifty  pulsations  in  a  minute.  To  tlie  questions 
directed  to  him  he  replied  only  by  monosyllables,  which 
frequently  had  no  connexion  whatever  with  the  subject  of  the 
question.  Neither  did  he  express  any  desire  for  food  or 
drink;  he  complained  of  no  distress  of  any  kind,  and  bore, 
without  evincing  the  slightest  sensation  of  pain,  a  depletion 
from  the  jugular  vein,  which  I  had  ordered  to  be  done  on  the 
spot.  This  depletion  I  directed  to  be  followed  up  forthwith 
by  the  application  of  cupping-glasses  to  the  regions  already 
mentioned,  and  of  ice  to  the  head,  while  the  patient  was 
plunged  into  a  demi-bath  at  a  temperature  of  25  degrees; 
finally  he  was  put  upon  a  diet  of  chicken  broth  and  cooling 
mucilaginous  drinks. 

All  the  symptoms  were  pretty  quickly  subdued  under  the 
influence  of  this  treatment,  and  I  believed  him  to  be  in  a  con- 
valescent state  sufficiently  safe  to  induce  me  to  send  him  home 
with  a  discharge  from  the  service  which  I  daily  expected  to 
receive,  when  in  the  night  of  the  21st  to  the  22d  of  the  same 
month  (the  barometer  having  risen  to  28  inches  8  lines),  new 
symptoms  supervened,  and  after  having  taken  during  the 
night  several  turns  through  the  hospital,  with  symptoms  of 
somnambulism,  he  jumped  a  second  time  over  the  garden  wall 
and  betook  himself  to  flight.  I  have  since  learnt  that  he  had 
repaired  to  his  place  of  nativity,  where  no  doubt  he  must  have 
regained  his  health. 

In  addition  to  the  above  cases,  I  shall  only  relate  a  summary 
of  that  of  one  Lewis  Stobler,  aged  21,  a  private  of  the  first  Swiss 
regiment  of  the  guards.  This  young  man,  after  having  repeat- 
edly told  his  comrades  of  his  ardent  desire  to  visit  his  parents  at 
home  in  Switzerland,  was  suddenly  seized  in  the  middle  of 
the  night  in  the  spring  of  1819  with  an  attack  of  nostalgia, 
during  which  he  precipitated  himself  from  the  window  of  the 
third  story  of  the  barracks,  with  the  intention,  as  he  subse- 
quently confessed,  to  break  a  leg,  in  order  to  be  discharged  and 
sent  back  to  his  country.  It  may  be  surmised  beforehand 
what  must  have  been  the  result  of  a  fall  so  violent,  the  principal 
effects  of  which  centred  in  the  right  leg  and  in  the  pelvis. 
The  shock  sustained  by  the  leg  was  attended   by  such  a  shat- 


Of  Nostalgia.  239 

tering  or  destruction,  that  its  amputation  had  been  rendered 
indispensable;  while  that  experienced  by  the  pelvis  and  loins 
resulted  in  a  complete  luxation  of  the  first  lumbar  upon  the 
body  of  the  last  dorsal  vertebra.  The  compression  exerted  in 
consequence  of  the  displacement  of  the  former  instantaneously 
caused  a  total  paralysis  of  the  lower  extremities,  of  the  bladder 
and  of  the  large  intestines.  The  brain  in  its  turn  had 
sustained  such  a  concussion  that,  notwithstanding  a  pretty 
considerable  hemorrhage  from  the  ears,  the  patient  had  been 
temporarily  deprived  of  the  powers  of  sensation,  locomotion 
and  intellect;  in  fine,  he  appeared  to  be  in  such  imminent  dan- 
ger, that  his  dissolution  was  expected  from  one  moment  to 
another.  We  nevertheless  lavished  upon  him  every  attention 
which  his  condition  seemed  to  require,  and  having  thus  suc- 
ceeded in  recalling  his  vital  powers,  he  was,  after  a  year  of 
uninterrupted  care  bestowed  upon  him,  finally  restored  to 
health,  the  luxation  of  the  vertebra,  however,  remaining  with 
a  few  degrees  lessening  in  the  displacement  of  this  bone,  and 
being  deprived  withal  of  his  right  leg.  At  that  period  this 
young  Swiss  no  longer  felt  the  desire  to  return  to  his  country; 
on  the  contrary,  he  signified  a  wish  to  be  admitted  into  the 
royal  hotel  of  the  invalids,  where  he,  being  a  foreigner,  could 
not  be  received,  and  to  his  great  sorrow  he  was  sent  back  to 
Switzerland. 

This  observation,  the  very  remarkable  details  of  which  will 
be  more  fully  developed  in  another  article,  conveys  the  fullest 
conviction  that  nostalgia  is  exclusively  seated  in  the  brain, 
which  in  the  present  instance  had  been  already  inflamed 
when  he  threw  himself  from  the  window,  and  that  the  spon- 
taneous hemorrhage  from  the  ears  at  the  moment  of  the  fall, 
the  blood-lettings  and  the  amputation  of  the  limb,  all  which 
were  successively  performed,  while  they  re-established  in  the 
cncephalon  the  equilibrium  of  all  its  functions,  they  at  the  same 
time  extinguished  in  this  soldier  the  settled  and  imperious 
necessity  to  return  to  his  country. 


240  Of  Phlebotomy  in  the  Jugular  Vein. 

Of  the  Operation  of  Blood-letting  from  the  Jugular  Vein 
and  Temporal  Artery. 

Authors  have  scarcely  said  anything  on  the  subject  of  this 
species  of  blood-letting,  and  nobody  has,  to  my  knowledge, 
pointed  out  any  of  the  precautions  necessary  to  be  taken  in 
order  to  perform  this  operation  with  safety  and  with  that  de- 
gree of  success  which  ought  to  attend  it;  in  fine,  no  physiolo- 
gical explanation  of  its  effects  has  been  as  yet  given  of  it,  when 
employed  for  the  purpose  of  relieving  the  sanguineous  con- 
gestions of  the  head.  With  a  view,  then,  of  supplying  this 
defect,  we  have  considered  it  a  useful  labour  to  indulge  in  a 
few  reflections  on  this  operation,  and  on  the  great  advantages 
to  be  derived  from  it  in  sanguineous  apoplexies  and  in  brain 
fevers. 

Blood-letting  from  the  jugular  vein  is  a  much  more  delicate 
operation  than  is  generally  supposed.  Even  when  the  vein  is 
very  distinct,  its  mobility  and  elasticity  render  it  difficult  to 
open  it;  very  frequently  it  lies  deeply  concealed  beneath  the 
platysma  myoides  muscle,  and  occasionally  it  is  altogether  im- 
perceptible. However,  in  almost  every  case  it  can  be  made 
to  appear  by  pressing  the  thumb  firmly  upon  its  course  between 
the  clavicular  attachment  of  the  tendon  of  the  sterno-cleido- 
mastoideus  and  the  anterior  margin  of  the  trapezius  muscle;  in 
the  next  place  the  skin  of  the  neck  should  be  kept  on  the 
stretch  by  the  finger  of  an  assistant,  below  the  angle  of  the 
jaw;  after  which  the  lancet  must  be  plunged  obliquely,  from 
below  upwards  and  outwards,  into  the  middle  of  the  vein, 
which  is  then  to  be  raised  up  finally  in  the  direction  of  the 
fleshy  fibres  of  the  platysma  myoid  muscle  by  which  it  is  co- 
vered. Care  should  be  taken  also  not  to  strike  too  perpendi- 
cularly with  the  point  of  the  instrument,  from  an  apprehension 
to  transfix  the  double  parietes  of  the  vein;  for  besides  the 
possibility  of  danger  from  wounding  some  of  the  nervous 
fibrillae  which  are  found  underneath  this  vein,  there  is  the 
liability  of  risk  from  the  formation  of  a  thrombus  in  the  sub- 
jacent cellular  texture  which  might  be  attended  with 
disastrous  consequences,  such  as  inflammation  and  suppuration 


Of  PhUhotomy  in  the  Jugular  Vein.  241 

of  this  texture  and  the  passage  of  the  purulent  matter  througli 
the  posterior  opening  of  the  vein  into  the  interior  of  this  vessel 
and  from  thence  into  the  heart.  Another  not  less  serious  acci- 
dent is  the  passage  of  air  with  the  globules  of  the  blood 
through  its  anterior  opening,  during  the  operation,  unless  the 
precaution  is  adopted  to  exert  a  permanent  and  uninterrupted 
compression  over  the  course  of  the  vein  below  the  orifice. 
This  precaution  is  one  of  the  most  important  to  be  taken  in 
practising  this  species  of  depletion. 

Now,  since  we  have  laid  down  the  rules  to  be  pursued  in  or- 
der to  perform  this  small  operation  with  perfect  safety,  we  shall 
briefly  mention  the  cases  in  which  it  is  not  only  proper,  but 
in  which  it  can  hardly  be  surrendered  for  venesection  from  the 
arms,  the  legs,  or  for  the  application  of  leeches. 

It  may  be  taken  as  a  general  rule  that  in  all  sanguineous 
congestions  of  the  head,  such  as  acute  fevers  of  the  brain,  spon- 
taneous sanguineous  apoplexies,  or  those  which  may  be  occa- 
sioned by  any  pressure  whatever  upon   the  jugular  vessels, 
this  kind  of  blood-letting  is  indispensable,   and  ought  to  be 
resorted  to  in  the  promptest  possible  manner.     It  cannot  be 
relinqjiished  for  bleeding  from  the  veins  of  the  extremities, 
because  the  first  effect  of  sanguineous  congestion  in  the  brain 
is  an  eccentric  or  concentric  pressure  (according  to  the  seat  of 
the  congestion),  upon  the  origin  of  the  nerves  arising  from  that 
organ,  from  whence  results  a  proportionate  paralysis  of  the 
lungs,  the  stomach  and  the  extensor  muscles  of  the  head,  which, 
by  virtue  of  its  own  gravitation,  is  inclined  to  the  bent  position 
the  more  easily  as  its  axis  does  not  conform  to  that  of  the  first 
cervical  vertebra  which  is  its  proper  fulcrum.     Thus,  this 
involuntary  and  permanent  flexion  will  soon  be  followed  by 
an  approximation  or  contact  of  the  parietes  of  the  jugular  vein 
at  its  origin  in  the  gulf  of  Louver,  the  only  communication 
of  the  vessels  with  black  blood  of  the  interior  of  the  cranium 
with  the  remainder  of  the  circulatory  system;  whereby  the 
free  circulation  of  the  blood  of  the  sinuses  of  the  dura  mater 
in   this  vein,  and  from  thence  to  the  heart,    becomes   sus- 
pended.    This  fluid,  which  therefore  must  flow  back  into  the 
sinuses  and  gradually  into  the  cerebral  veins,  increases  the 
2  F 


242  Of  t^rteriotomif. 

congestion  of  course,  and  aggravates  the  evil.  Other  methods^ 
of  depletion,  while  on  one  side  they  reduce  the  vital  powers 
of  the  system,  on  the  other  are  instrumental  in  augmenting  the 
consequences  of  paralysis  which  have  been  spoken  ofy  whereby 
the  obliteration  of  the  parietes  of  the  jugular  vein  will,  there- 
fore, become  even  more  decidedly  marked,  whereas  the  open- 
ing of  the  latter  vessel  empties  the  meningeal  sinuses  in  a 
direct  manner,  and  thus  unloads  at  once  the  deep  seated  vessels 
of  the  brain.  The  congestion  will  then  terminate  by  resolu- 
tion, as  far  as  it  may  be  susceptible,  and  the  encephalic  nerves, 
being  no  longer  compressed  at  their  origin,  will  again  transmit 
the  electric  stimulus  to  the  enfeebled  organs,  the  functions  of 
which  will  immediately  be  re-established.  This  internal 
resolution  may  in  the  next  place  be  accelerated  by  repeated 
applications  of  scarified  cups  to  the  nape  of  the  neck  and  to 
both  sides  of  the  spine,  by  the  employment  of  sedatives,  such 
as  ice  put  upon  the  head,  and  of  revulsives  to  the  base  of  the 
cranium.  A  cooling  and  mucilaginous  diet  will  also  materi- 
ally assist  this  mode  of  treatment. 

Of  the  Operation  for  Jlrteriotomy. 
The  opening  of  the  temporal  artery  is  indicated  in  all  acute 
phlegmasise  of  the  epicranial  membranes  (aponeurotic  and 
muscular  expansions),  in  that  inflammatory  condition  super- 
vening after  injuries  of  the  head,  and  in  meningeal  inflam- 
mations, provided  they  can  be  distinguished  from  genuine 
affections  of  the  brain.  In  order  to  perform  this  operation  ^ 
the  lancet  is  to  be  used  in  preference  to  the  bistoury,  inas- 
much as  the  former  will  merely  divide  the  anterior  or  external 
coats  of  the  artery,  so  that  the  divided  extremities  of  the  vessel 
cannot  retract  again,  and  the  blood  continues  to  flow  without 
interruption,  yielding  thus  any  quantity  which  it  may  be  desi- 
rable to  obtain.  Besides  the  inconvenience  of  dividing  the 
whole  caliber  of  the  tube,  the  bistoury  may,  moreover,  imper- 
fectly divide  some  of  the  filaments  of  the  facial  nerve,  the  lesion 
of  which  might  be  attended  by  tic  douloureux  or  neuralgiaof  the 
face.  The  flow  of  blood  may  be  arrested  afterwards  by  means 
of  the  nodose  bandage  (noeud  d'emballeur)  and  the  dressing 


Vf  the  Nervous  System  of  lielallon.  243 

«hould  be  allowed  to  remain,  till  the  small  orifice  of  the  wound 
shall  be  cicatrized  entirely.  It  frequently  happens  that  the 
blood  continues  to  circulate  in  the  same  wounded  branch  of 
the  artery,  the  orifice  of  which  has  become  closed,  in  the  same 
way  as  that  of  one  of  the  veins  of  the  arm  in  a  case  of  ordinary 
venesection.  If  the  vessel  has  been  cut  completely  across,  both 
«nds  then  retract  and  the  hemorrhage  stops,  in  which  case  the 
circulation  afterwards  will  be  interrupted  in  this  arterial 
branch,  which  is  obliterated  and  disappears.  If,  however,  iu 
the  first  instance,  the  slight  pressure  on  the  wounded  artery 
,be  too  soon  removed,  although  the  orifice  should  be  cicatrized, 
a  small  encysted  aneurism  is  then  frequently  formed  beneath 
this  cicatrix,  which  can  be  made  promptly  to  disappear  by  re- 
newed and  isolated  compression.  (See  the  article  Jlneurism^ 
Clin.  Chirurg,  Vol.  III.) 

Of  the  Nervous  System  of  Relation, 
In  order  to  form  a  correct  idea  of  what  we  have  said  in  the 
preceding  articles,  relative  to  the  distinct  origin,  in  dijîerent 
parts  of  the  encephalon,  of  the  nervous  filaments  of  which  the 
nervous  system  of  relation  consists,  we  intend  to  republish  on 
this  occasion  the  memoir  which  we  wrote  at  another  time  on 
the  subject  of  the  origin  of  these  nervous  root^,  and  of  the 
particular  functions  over  which  each  appears  to  preside,  by 
describing,  for  the  purpose  of  a  comparison  with  our  own 
theory,  the  mechanism  of  an  electric  telegraph  which  has  been 
invented  by  the  celebrated  Sœmmering.  This  telegraph, 
which  on  my  journey  to  Munich  I  received  from  the  hands 
of  the  author  himself,  had  been  laid  before  the  Institute  of 
France,  at  the  commencement  of  the  year  1810;  but  the  aca- 
demy having  made  no  report  on  this  instrument,  I  returned  it 
to  the  inventor,  not  without  the  precaution,  however,  of  hav- 
ing it  copied.  We  shall,  therefore,  begin  by  describing  this 
instrument  as  briefly  as  possible,  and  proceed  afterwards  to  the 
parallel  which  we  have  drawn  with  it  of  the  origin,  the  course 
and  the  distribution  of  the  nervous  system  of  relation. 

This  telegraph  consists  of  a  fixed  number  of  metallic  wires 
(there  may  be  thirty-five),  establishing  a  communication  be- 


244  Of  the.  Nervous  SyaUin  of  Relation. 

tweeii  the  two  principal  pieces  of  the  instrument,  which  are 
denominated  the  interrogator  and  the  respondent.  There 
are  on  the  interrogator  a  range  of  metallic  cross-bars  placed 
horizontally  and  at  equal  distances  from  one  another,  which 
correspond  to  particular  signs  (the  letters  of  the  alphabet). 
Each  of  these  bars  presents  at  one  of  its  extremities  a  hole 
large  enough  to  admit  the  points  of  two  electrical  conductors, 
and  another  considerably  smaller  for  the  passage  of  the  metallic 
wire.  These  wires,  separated  at  first  at  the  points  of  their 
insertion,  and  isolated  in  their  whole  extent  by  threads  of  silk, 
afterwards  approximate  each  other  and  come  in  juxta-position, 
so  as  to  form  a  common  cord  so  tightly  twined  as  to  appear  to 
be  of  a  simple  or  unique  texture.  These  wires  run  parallel,  or 
intersect  one  another,  in  their  course,  and  experience  various 
inflections;  and  after  having  travelled  over  a  certain  space, 
they  again  separate,  diverge  and  anastomose  or  articulate  with 
some  points  of  gold  which  are  placed  vertically  in  a  glass  vase 
of  the  shape  of  an  oblong  square,  forming  thus  the  largest  part 
of  the  respondent.  The  signs  which  we  noticed  at  the  inser- 
tion of  the  wires,  are  repeated  opposite  the  points  of  gold. 
The  vase  must  be  filled  with  pure  and  clear  water. 

When  some  electric  fluid  produced  by  an  electric  machine 
or  the  Voltaic  pile  is  transmitted  by  means  of  the  conductors 
coming  from  the  two  poles  of  this  column,  the  electric  fluid 
travels  without  any  impediment  along  the  whole  passage  of 
each  metallic  wire,  without  passing  over  to  those  which  are 
contiguous  to  it,  notwithstanding  their  interlacing  or  intersect- 
ing one  another.  This  fluid  then  goes  to  the  corresponding 
gold  point.  The  electricity  issuing  from  the  negative  pole 
instantly  disengages  hydrogen  (from  the  water  in  the  jar), 
while  that  proceeding  from  the  positive  pole  liberates  oxygen. 
Here  these  gases  become  perceptible  by  the  accumulation  of 
air-bubbles  which  creep  upon  the  points  of  gold  and  rise  in  a 
jet  without  the  least  obstacle  to  the  surface  of  the  water,  where 
they  may  be  received  with  gasometers.  In  this  way  it  is  easy 
to  determine  the  quantity  and  the  nature  of  the  gases  disen- 
gaged in  a  given  space  of  time.     Such  are  nearly  all  the  chief 


Of  the  Nervous  System  of  Relation.  245 

characteristics  and  the  principal  results  of  Doctor  Sœmmering's 
electrical  telegraph. 

Now,  the  nervous  system,  especially  that  of  relation,  appears 
to  be  distributed  upon  a  similar  plan,  and  presents  in  its  func- 
tions analogous  phenomena.  Those  nervous  filaments,  for 
example,  which  derive  their  origin  in  this  or  that  part  of  the 
brain,  of  the  medulla  oblongata  or  of  the  spinal  marrow,  do 
nevertheless  not  blend  their  functions  with  those  of  other  fila- 
ments which  arise  below,  or  higher  up,  or  at  a  greater  distance. 
And  although  they  may  unite,  in  the  formation  of  nervous 
ramifications,  branches,  or  trunks,  yet  they  are  isolated  by 
their  particular  neurileme  and  glued  to  one  another. 

Several  great  anatomists  have  already  observed  the  isolation 
of  the  nervous  fibrillae  which  compose  the  large  cords  of 
nerves,  their  branches  and  their  ramifications,  whether  they 
intersect  each  other,  or  run  parallel  and  without  becoming  at 
all  confounded.  Every  body  has  it  in  his  power  k»  verify  the 
experiments  of  these  anatomists.  If,  for  instance,  somebody 
will  take  the  trouble  of  dissecting  somewhat  carefully  the  ner- 
vous filaments  of  the  sciatic  or  of  the  median  nerve,  he  may, 
indeed,  trace  these  filaments  very  distinctly.  They  are 
parallel  to  their  origin  so  long  as  the  nervous  trunk  gives  off 
no  branches,  or  suffers  no  inflexion.  When  this  happens,  these 
filaments  cross  each  other  in  such  a  way  that  the  anterior  be- 
come posterior  and  vice  versa;  at  last  they  separate  by  diver- 
ging, form  branches,  twigs,  ramifications,  and  go  to  their 
respective  destination.  Some  supply  the  muscles,  others  the 
skin,  the  cellular  tissue,  &c.  but  in  such  a  manner  that  each  of 
these  filaments  may  fulfil  some  distinct  function,  according 
to  its  origin  from  this  or  that  part  of  the  medullary  substance, 
the  medulla  oblongata  or  the  spinal  marrow. 

The  two  nervous  cords  of  the  seventh  pair,  it  seems  to  me, 
furnish  a  striking  example  of  the  truth  or  probability  of 
my  assertion.  The  portio  mollis  or  acoustic  nerve  arises 
from  the  anterior  wall  of  the  fourth  ventricle  of  the  brain  by 
two  or  more  small  cords  or  fibrillae,  whilst  the  portio  dura  or 
facial  nerve  takes  its  origin  far  below  and  more  behind  the 
first  in  the  groove  which  separates  the  cerebral  or  annular  pro- 


246  Of  the.  Nervous  System  of  Relation. 

tuberance  from  the  medulla  oblongata  at  the  summit  of  the 
eminentiae  olivares,  The  former  of  these,  more  elevated 
towards  the  positive  pole  of  the  medulla  oblongata  than  the 
other,  is  destined  to  form  the  organ  of  hearing;  the  latter,  on 
the  contrary,  which  is  nearer  to  the  negative  pole,  is  destined 
to  endow  the  muscles  of  the  face  with  the  power  of  motion, 
and  the  skin  and  certain  glandular  structures  of  that  part  with 
feeling  or  sensibility.  The  same  disposition  holds  no  doubt 
with  regard  to  the  lingual  nerves,  some  of  which  are  subser- 
vient to  taste  and  others  to  speech;  they  certainly  have  a  dis- 
tinct origin  and  stand  in  an  analogous  relationship. 

The  branches  which  the  median  nerve,  for  example,  sends 
to  the  muscles  of  the  arm,  fore-arm  and  the  hand,  for  the  pur- 
pose of  endowing  them  with  motion,  have  surely  not  the  same 
origin  in  the  spinal  marrow  as  those  which  it  furnishes  to  the 
skin  in  order  to  impart  sensation  to  it;  and  for  the  same 
reasons  the  fluid,  which  passes  through  these  different  elemen- 
tary nerves,  must  experience  corresponding  modifications:  and 
hence  proceed  the  various  sensations  with  their  different  results. 

The  neurileme  stands  in  the  same  relation  to  the  nervous 
substance  or  to  the  real  elementary  nerve,  in  which  the  thread 
of  silk  stands  to  each  metallic  wire  of  the  telegraph  of  Sœm- 
mering;  the  common  membranous  sheath  surrounding  the 
nervous  trunks  represents  the  silk  ribbon  in  which  the  metallic 
cord  of  the  telegraph  is  enveloped  ;  thus  this  instrument  might 
perhaps  be  styled  with  greater  propriety  the  simulacrum  ner- 
vorum. 

We  have  moreover  reason  to  believe  that  the  intensity  and 
the  force  of  excitement  of  the  nervous  fluid  are  in  the  ratio  of 
the  pole  of  the  encephalon  or  animal  electromotor.  It  is  not 
unlikely  that  there  are  as  many  galvanic  columns  in  the  brain, 
as  there  are  distinct  portions  in  both  the  medulla  oblongata 
and  spinal  marrow.  They  are  composed,  as  in  the  metallic 
pile,  of  different  substances,  one  placed  over  the  other,  which 
consist  chiefly  of  the  grey  or  cineritious  substance,  and  of  the 
white  medullary  or  nervous  substance.  Vascular  membranes 
sometimes  form  the  points  of  separation  or  the  bonds  of  union 
between  each  other.     They  form  piles  or  layers  of  various 


Of  the  Nervous  Syste^n  of  Relation.  247 

thickness.  The  internal  nervous  commissures,  so  well 
described  by  Doctor  Gall,  may  be  considered  as  so  many 
particular  conductors  which  establish  as  many  ways  of  com- 
munication between  the  piles,  between  the  latter  and  the 
nerves  themselves,  or  general  conductors.  These  conductors 
always  derive  their  origin  from  the  white  substance,  as  the 
metallic  conductors  come  from  the  disks  of  zinc  or  silver. 
TJiese  two  substances  exist  in  every  portion  of  the  brain,  from 
whence  nerves  arise  at  all;  they  are  consequently  to  be  met 
with  in  the  medulla  oblongata  as  well  as  in  the  spinal  marrow. 

In  admitting  the  identity  of  the  nervous  fluid  with  the  elec- 
trical fluid,  as  it  seems  to  be  confirmed  by  the  experiments  of 
Galvani,  Volta,  Ritter,  Davy,  and  Sœmmering,  it  would  ap- 
pear that  this  fluid  is  in  the  first  instance  concentrated  on  the 
piles  of  the  encephalon,  where  it  is  carried  by  the  arteries,  or 
perhaps  by  some  other  external  conductors,  such  as  hair,  &c. 
that  this  fluid  variously  modified,  according  to  the  points  or 
animal  piles  which  produce  it,  is  afterwards  transmitted  and 
distributed  to  the  different  nerves  of  animal  life  in  order  to 
excite  the  phenomena  peculiar  to  it.  This  fluid,  after  having 
undergone  some  modifications,  communicates  with  the  nerves 
of  organic  life;  and  the  fluid  which  prevails  in  the  latter  is 
modified  again  or  excited  by  ganglions  which  may  be  looked 
upon  as  so  many  small  and  independent  brains. 

All  this  proves  that  the  intellectual  and  sensitive  functions 
are  executed  by  agents  distinct  from  one  another,  by  which 
different  results  are  produced,  although  there  may  exist  a 
communication  and  sympathy  between  the  organs  concerned. 
Thus,  we  shall  suppose  that  the  nerves  which  arise  from  the 
negative  pole  of  such  or  such  a  pile  give  motive  power  to  the 
muscles,  as  the  conductors  of  a  more  powerful  and  more  active 
principle.  Specimens  of  it  may  be  found,  I  think,  in  the  pile 
of  the  medulla  oblongata  which  has  for  its  base  the  centre  of 
the  medullary  substance  of  the  brain.  We  perceive  all  the 
most  delicate  nerves  of  sensation  arising  from  the  superior 
part  of  the  positive  pole,  which  in  the  telegraphic  instrument 
disengages  oxygen,  which  is  minus;  such  are  the  olfactory,  the 
auditory,  the  optic  nerves,  &c.;  whilst  those  which  minister 


248  Of  the  Nervous  System  of  Belation. 

to  the  functions  requiring  a  greater  degree  of  intensity,  as  those 
of  the  muscular  tissue,  take  their  origin  from  a  more  inferior 
part  of  the  medulla  oblongata,  or  in  the  direction  of  the  nega- 
tive pole,  which,  in  the  telegraph  of  Sœmmering,  produces 
hydrogen  which  is  in  excess.  And  the  same  obtains  in  the 
two  pyramids  or  columns  of  which  the  spinal  marrow  appears 
to  be  composed. 

Here  we  are  struck  by  a  singular  phenomenon  which  sup- 
ports this  assertion.  The  spinal  nerve  of  Willis  which 
anastomoses  with  the  par  vagum  or  eighth  pair  of  nerves,  and 
which  is  exclusively  appropriated  to  the  posterior  muscles  of 
the  shoulder,  arises  exactly  at  the  negative  pole  of  the  first 
part  of  the  spinal  marrow,  or  from  its  first  pile,  whilst  the 
latter,  which  is  appropriated  to  the  internal  and  more  delicate 
sensitive  functions,  arises  from  its  positive  pole,  or  from  its 
superior  part.  I  believe  that  the  same  arrangement  prevails 
throughout  all  the  other  nerves  of  animal  life,  although  their 
elementary  fibres  are  apparently  confounded  in  their  trunks 
and  identified  between  themselves. 

If  the  celebrated  Lionnet  who  has  given  an  exact  and  minute 
anatomical  description  of  a  great  many  animalcules,  such  as 
the  puceron,  the  common  flea,  the  scarus,  &c.  had  been 
charged  with  the  dissection  of  these  elementary  nervous  fila- 
ments, he  would  have  traced  their  trunks  to  their  real  and 
distinct  origin,  as  well  as  to  their  termination,  and  it  is  proba- 
ble that  we  should  now  have  been  enabled  to  verify  this  sur- 
prising and  beautiful  analogy  between  the  electrical  operations 
made  by  means  of  the  above  cited  instrument  and  the 
operations  relative  to  the  nerves  of  animal  life.  Similar 
researches,  the  pursuit  of  which  belongs  only  to  physiologists 
ex  professo,  would  doubtless  contribute  to  an  explanation  of 
many  phenomena  which  are  still  wrapped  in  the  veil  of 
mystery. 

The  nerves  of  organic  life  enjoy  another  mode  of  existence, 
but  as  there  is  so  great  an  analogy  in  their  properties  that, 
wherever  they  may  be  distributed,  they  produce  efiects  of 
vitality  or  excitability  almost  alike;  and  that  the  modifications 
of  these  properties  seem  to  reside  in  the  ganglions;  we  shall 


Of  the  Nervous  System  of  Relation.  249 

not,  for  the  present,  start  any  hypothesis  at  all  on  this  system 
of  nerves.  I  shall  merely  observe  that  the  nervous  fasciculi, 
proceeding  from  the  two  great  sympathetic  nerves,  necessarily 
accompany  the  arterial  trunks,  the  branches  and  ramifications 
to  their  most  minute  distribution  into  the  substance  of  the 
parts,  as  has  been  already  advanced  by  several  great  anato- 
mists, such  as  Bichat,  Chaussier,  Ribes,  &c. 

At  the  shambles  of  armies,  where  I  frequently  made  some 
experiments,  I  have  had  occasion  to  witness  two  of  these 
nerves  in  the  foetuses  of  cows  accompanying  the  umbilical 
arteries  into  the  ramifications  of  the  placenta,  and  others 
following  the  course  of  the  subclavian  and  crural  arteries  as 
far  as  their  first  branches;  nor  is  it  doubtful  any  longer  that 
they  extend  even  to  their  farthest  ramifications.  1  believe, 
moreover,  that  these  great  sympathetic  nerves  propagate  or- 
ganic life  into  the  osseous  membranes,  the  articular  ligaments 
and  the  synovial  membranes;  for  the  slightest  injury  of  these 
parts  by  some  cause  operating  for  a  certain  length  of  time, 
violently  attacks  the  organic  properties  of  the  limb,  and 
immediately  disturbs  the  functions  of  the  internal  organs. 


2G 


OF  THE  INJURIES  OF  SOME  PARTS  OF  THE  FACE. 


1 .  Of  Lesions  of  the  Ear. 

Solutions  of  continuit}^  of  the  external  ear  vary  according  to 
the  extent,  the  shape  and  the  nature  of  the  causes  which  pro- 
duced them.  Incised  wounds  or  divisions  made  by  sharp 
instruments  may  be  limited  to  a  portion  of  the  ear,  or  they 
may  include  almost  the  whole  of  its  extent;  for  when  it  has 
been  cut  off  entirel}''  and  separated  from  the  head,  there  is 
nothing  to  be  done  in  order  to  restore  it  to  its  primitive  rela- 
tions. Every  attempt  to  accomplish  such  an  object  will  prove 
abortive,  for  its  adhesion  to  the  parts  from  which  it  may  have 
been  completely  detached  will  never  again  take  place.  In 
every  other  case,  and  be  the  point  never  so  little  by  which 
the  divided  flap  adheres  to  the  remainder  of  the  ear  or  to  the 
margin  of  the  meatus  auditorius,  immediate  re-union  is  at  once 
indicated,  and  should  be  done  by  means  of  needles  (of  which 
we  have  spoken  in  the  article  on  Wounds,  see  pages  4  and  5), 
and  by  having  recourse  to  the  interrupted  suture.  The  carti- 
lages, forming  the  external  ear,  as  we  have  already  stated, 
should  be  included  within  the  stitches  of  the  suture;  no  un- 
pleasant symptom  will  result  from  it,  and  the  suture  will  only 
be  the  more  exact  and  firm.  Care  should  be  taken  to  fill  up 
with  charpie  the  intermediate  spaces  of  the  sinuosities  of  the 
ear  and  the  channel  by  which  it  is  separated  from  the  temple. 
The  dressing  may  be  completed  by  a  common  retaining 
bandage,  which,  as  far  as  may  be  expedient,  should  not  be 
disturbed  until  the  very  moment  of  complete  cicatrization. 
Such  then  is  the  operative  process  or  the  mode  of  dressing 


Of  Lrsions  of  Ihr,  Ear.  251 

which  has  appeared  to  us  to  be  the  best  aclapteil  for  simple  or 
incised  wounds  of  the  ear. 

But,  if  these  divisions  are  unequal  or  jagged,  which  necessa- 
rily happens  when  the  instrument  itself,  wliich  has  caused  the 
solution  of  continuity,  presents  inecpialities  iu  the  acting  sur- 
face, then  the  indication  is,  of  course,  diflerent.  In  that  case, 
it  is  necessary  to  use  a  pair  of  cui'ved  scissors  and  cut  the 
edges  of  the  division  smooth,  in  order  thus  better  to  bring 
them  in  close  apposition  and  to  produce  an  uniform  cicatrix. 

This  kind  of  wounds  is  frequently  the  result  of  bites  from 
men  or  from  animals.     It  is,   indeed,  no  rare  occurrence  to 
witness  violent  scuflles  amongst  individuals  of  the  human  spe- 
cies terminate  by  bites  into  the  ears,  the  chin  or  the  lips;  I 
liave  seen  that  repeatedly  even  among  soldiers;  but  it  is  from 
motives  of  self-love  that  such  persons  carefully  endeavour  to 
hide  this  cause  as  well  as  every  vestige  of  its  effects;  for  of  all 
weapons  which  man  may  make  use  of  for  the  purpose  of 
avenging  some  insult,  this  doubtless  is  the  most  ignoble.   The 
knowledge  of  this  circumstance  ought  to  put  the  medical  jurist 
on  his  guard,  lest  he  might  suffer  himself  to  be  misled  by  false 
statements  or  by  the  interest  of  the  wounded  man.     In  this 
way  I  was  enabled  to  clear  up  the  proofs  advanced  in  support 
of  pretensions  to  certain  titles  or  rewards  which  on  some  occa- 
sion had  been  claimed  by  a  military  man,  who  stated  tiiat  he 
had  been  wounded  by  the  hands  of  a  stranger  armed  with  his 
own  sword,  while  the  truth  of  the  matter  was  that  his  ear  had 
been  bitten  off  by  the  teeth  of  some  man  or  woman.     The  well 
marked  denticulated  notches  displayed  on  the  borders  of  M.'s 
wound,  which  extended  transversely  from  before  backwards 
over  one  half  of  the  external  ear,  left  not  the  least  doubt  on 
my  mind  as  to  the  nature  and  shape  of  the  offending  cause. 
My  substantiated  report  destroyed  the  illusion  and  put  a  stop 
to  an  investigation  which  in  all  probability  would  have  com- 
promised a  great  many  innocent  persons. 

After  having  made  my  report  on  the  state  of  the  wounded 
Marie,  I  proceeded  to  dress  his  wounds,  the  most  serious  of 
which  was  that  of  the  ear.     I  cut  out  the  denticulated  edges 


252  Of  Lesions  of  the  Ear. 

with  a  pair  of  curved  scissors,  and  reunited  them  afterwards 
by  means  of  five  stitches  of  the  interrupted  suture;  the  re- 
mainder of  the  dressing  was  made  on  the  principles  above 
mentioned,  and  was  not  taken  off  until  the  ninth  day,  when 
the  reunion  and  cicatrix  of  the  wound  were  completed.  The 
knots  of  the  ligature  were  cut  off,  and  the  ear,  when  measured 
and  compared  to  that  of  the  sound  side,  presented  a  diminution 
of  about  three  lines, — the  result  of  the  resection  of  the  edges 
of  the  wound.  In  other  respects  the  shape  and  arrangement 
of  the  concha  of  the  ear  had  been  preserved  entire. 

The  application  of  the  principle  which  we  have  advocated 
for  jagged  or  lacerated  wounds  of  the  ear,  is  equally  suited  to 
gun-shot  wounds  of  this  part;  or  in  other  words,  it  will  be  pro- 
per to  convert,  by  means  of  resection,  uneven  wounds  into 
simple  ones,  and  to  reunite  them  afterwards  by  the  measures 
best  adapted  to  the  latter. 

In  all  injuries  of  the  meatus  auditorius,  particularly  when  ac- 
companied with  loss  of  substance,  the  attention  of  the  surgeon 
should  be  directed  to  prevent  the  agglutination  of  the  parietes 
and  the  obliteration  of  the  meatus.     One  instance  of  such  an 
accident  occurred  to   a  soldier  who,  during  the  last  siege  of 
Paris,  had  been  wounded  by  a  ball,  in  consequence  of  which 
the  meatus  auditorius  of  the  right  ear  had  been  grazed  or 
notched.     This  man  spent  several  months  at  (the  hospital  of) 
Val-de-Grace,  where  being  treated  for  his  wound,  he  lost, 
according  to  his  own  statement,  several  small  pieces  of  the 
meatus  itself,  besides  all  the  small  bones  of  the  ear.     When  I 
had  an  opportunity  to  see  him,  there  was  a  cicatrix  observable 
at  the  auditory  region  of  the  right  ear,  involving  the  total  loss 
of  the  two  eminences,  denominated  tragus  and  anti-tragus. 
The  meatus  was  hermetically  closed  by  the  cutaneous  pellicle 
which  contributed  to  the  formation  of  the  cicatrix,  which  in 
itself  was  very  small,  elastic  and  of  exquisite  sensibility.    The 
lateral  margins  of  the  concha  were  approximating  each  other, 
and  the  remainder  of  the  external  ear  slightly  inclining  for- 
wards,   whilst   the    kind  of   covering   without  aperture,    to 
which  we  have  alluded,  was  depressed  towards  the  bottom  of 


Of  Lesions  of  the  Ear.  253 

the  meatus,  where  it  appeared  to  us  closely  to  approximate 
the  cavity  of  the  tympanum. 

Buta  surprising  circumstance  was  the  fact,  that  this  soldier, 
after  we  had  taken  the  precaution  of  hermetically  closing  the 
right  ear,  could  still  hear  most  distinctly,  even  what  was 
spoken  in  a  low  voice,  with  the  ear  of  the  right  or  affected 
side,  although  its  meatus  was  completely  closed  by  the  prolon- 
gation of  the  dermoid  cicatrix  forming  the  covering  (l'oper- 
cule). Nature  no  doubt  had  modified  and  moulded  it  in  such 
a  way  as  to  replace  the  membrana  tympani  which  had  been 
destroyed  by  the  effects  of  the  gun-shot  wound.  In  other 
respects  I  must  let  physiologists  explain  this  singular  piece  of 
mechanism,  which  greatly  enlisted  the  attention  of  the  mem- 
bers of  the  philomathic  society  to  whom  this  soldier  had  been 
presented  in  one  of  their  meetings,  during  the  winter  of  1815 
to  1816. 

It  often  happens  that  dossils  of  cotton  are  forcibly  and  care- 
lessly pushed  into  the  meatus  auditorius,  so  that  this  substance 
sinks  deeply  into  that  cavity,  coils  itself  up  there,  and  con- 
tracts so  much  as  to  disappear  entirely;  we  have  found  them 
repeatedly  at  the  very  bottom  of  the  ear.  From  this  circum- 
stance results  a  new  cause  of-  deafness  which  the  individual 
never  suspects;  and  he  keeps  afterwards  this  foreign  body  the 
longer,  as  it  is  scarcely  visible,  and  moreover  covered  with 
cerumen.  It  may,  however,  be  discovered  by  separating  the 
parietes  of  the  meatus  with  a  pair  of  forceps,  with  which  it 
may  be  seized  afterwards,  when  its  extraction  is  as  easy  as  it 
can  be  rendered  expeditious. 

A  young  non-commissioned  officer  of  the  guards  came  to 
our  hospital  complaining  of  pain  in  the  ear  from  which  he  had 
suffered  for  several  years.  It  was  kept  up,  so  he  told  us,  by 
the  presence  of  a  milk-tooth  which  he  had  himself  put  into  the 
meatus  of  the  right  ear,  while  at  play  with  his  school-fellows. 
This  tooth  was  lodged  deeply  in  the  meatus,  where  it  touched 
upon  the  tympanum,  so  that  by  the  most  minute  examination 
a  small  spot  could  be  perceived  only  Avith  difficulty.  I,  there- 
fore, had  a  small  pair  of  forceps  made  adapted  to  the  periphery 
of  the  meatus,  and  by  these  means  I  succeeded,  not  without 


254  Of  Lesions  of  the  Ear. 

some  trouble,  in  the  extraction  of  the  foreign  substance.  The 
young  man  soon  got  well  again  and  left  the  hospital  a  few  days 
afterwards. 

There  is  yet  another  cause  of  deafness  which  appears  to  have 
escaped  the  observation  of  those  who  have  made  this  disorder 
their  particular  study.  This  is  a  species  of  mal-formation 
which  supervenes  at  an  age  more  or  less  advanced,  or  perhaps 
after  some  accident,  and  which  operates  upon  the  parietes  of 
the  auditory  passage.  In  persons,  for  example,  who  in  early 
life  lose  the  molar  teeth  of  one  or  the  other  maxilla,  there  will 
result  from  it  a  gradual  displacement,  upwards  and  backwards, 
of  the  condyles  of  the  lower  jaw-bone,  which  sink  into  the 
glenoid  cavities  of  the  temporal  bones,  so  as  to  become  lodged 
at  the  bottom  of  these  articular  cavities,  beyond  the  glenoidal 
fissure  (la  scissure  de  Glaser)  and  before  the  meatus  externus, 
the  parietes  of  which  will  then  be  depressed  in  the  same  di- 
rection; the  auditory  passage  is  gradually  obliterated,  or  under- 
goes such  an  alteration  that  the  rays  of  sound  can  no  longer 
reach  the  tympanum,  from  whence  results  deafness.  Although 
collected  by  the  tortuous  folds  of  the  concha,  these  rays  con- 
centrate themselves  merely  in  the  oblique  and  deep-seated 
fossa  which  may  be  observed  before  the  orifice  of  this  passage 
and  at  the  base  of  the  lobus.  Under  such  circumstances  the 
perception  of  sound  by  the  internal  ear  cannot  take  place;  the 
derangement  of  this  canal  produced  by  the  pressure  which  the 
condyles  of  the  jaw  exert  upon  its  parietes,  in  proportion  to 
the  change  of  relation,  induced  by  the  loss  of  all  or  of  the 
greater  part  of  the  m.olar  teeth,  must  therefore  be  looked  upon 
as  the  immediate  cause  of  this  malformation. 

The  lymphatic  glands  in  the  vicinity  of  these  passages,, 
whenever  they  become  engorged,  may  be  the  cause  of  a  similar 
imperfection  and  of  deafness;  we  have  noticed  this  repeatedly 
in  persons  attacked  v>^ith  scrofula. 

Ill-shaped  cicatrices  resulting  from  wounds  of  the  meatus 
may  be  attended  by  the  same  consequences.  In  order  to  pre- 
serve the  integrity  of  the  auditory  faculties,  it  is  therefore  of 
great  moment,  when  such  wounds  are  about  to  cicatrize,  to  be 


Of  Lesions  of  the  Ear.  255 

careful  of  the  preservation  of  the  caliber  and  of  tlie  natural  or 
normal  direction  of  tlic  meatus  audilorius. 

In  order  to  recognise  the  deformity  of  which  we  are  speak- 
ing, it  will  suflice  to  compare  the  connexion  between  the 
sinuosities  of  the  concha  and  their  reunion  at  tlic  bottom  of 
their  cone  with  the  orifice  of  the  meatus  auditorius,  and  to 
examine  this  passage  well,  so  as  to  be  sure  at  the  same  time 
that  it  contains  no  foreign  substance  capable  of  opposing  the 
unimpeded  entrance  of  the  rays  of  sound. 

In  case  of  an  unnatural  deviation,  induced  by  some  of  the 
above  enumerated  causes,  it  will  be  readily  understood  that 
the  want  of  proper  connexion  between  the  orifice  of  the  ex- 
ternal meatus  and  the  inferior  extremity  of  the  concha  impedes 
the  entrance  into  the  internal  ear,  of  the  sounds  which  the 
concha  had  collected  at  the  margin  of  that  orifice,  where  they 
afterwards  become  lost  in  part  or  entirely,  according  to  the 
extent  of  the  deviation  of  the  meatus;  and  that  the  degree  of 
deafness  will,  of  course,  be  in  the  same  proportion. 

Any  organic  lesion  of  this  kind  may  be  ascertained  by  means 
of  a  small  trumpet,  which  can  be  made,  on  the  spot,  out  of  a 
playing  card.  Armed  with  this  instrument  the  perception  of 
sounds  goes  on  as  usual,  so  that  this  experiment  will  suggest 
to  the  physician  the  indication  which  he  has  to  fulfil.  This 
indication  then  consists  in  causing  to  disappear,  with  the  aid 
of  an  acoustic  trumpet,  the  obstacles  which  the  rays  of  sound 
meet  with  in  their  career  through  the  sinuosities  of  the  exter- 
nal ear  to  the  meatus.  But  the  greatest  difficulty  in  the 
application  of  this  remedy  is  its  adaptation  to  the  ear,  without 
having  recourse  to  an  external  spring  and  without  the  indi- 
vidual being  under  the  necessity  of  holding  the  trumpet  with 
his  hand,  which  is  fraught  with  great  inconvenience,  the  most 
irksome  of  which,  no  doubt,  is  to  expose  his  infirmity  to  public 
observation. 

It  has,  therefore,  been  necessary  to  invent  a  trumpet  which 
should  possess  the  qualification  of  collecting  and  of  transmit- 
ting directly  to  the  auditory  passage  the  rays  of  sound  which 
strike  upon  the  external  ear,  and  in  the  next  place  to  contrive 
a  plan  for  keeping  this  trumpet  in  its  place  without  subjecting 


256  Of  Lesions  of  the  Ear. 

the  person  to  the  least  restraint,  or  to  the  eflfects  of  a  mechani- 
cal apparatus. 

The  trials  which  I  had  at  first  made  with  metallic  trumpets 
did  not  at  all  justify,  by  the  result,  my  expectation  from  them. 
The  contact  of  these  bodies  with  the  internal  membrane  of 
the  meatus  auditorius  caused  a  sensation  extremely  uncom- 
fortable to  the  individual,  which  was  increased  by  the  rise  of 
the  thermometer,  or  near  some  place  of  artificial  heat,  inas- 
much as  this  instrument,  being  an  excellent  conductor  of 
caloric,  became  heated  in  the  same  proportion.  I  then  con- 
ceived the  idea  of  getting  trumpets  made  of  gum  elastic, 
contracted  in  such  a  manner  that  their  margin  should  be  in 
contact  with  the  folds  of  the  anti-helix,  tragus  and  anti-tragus 
of  the  ear,  and  that  it  should  be  kept  in  this  position,  without 
any  external  fastening  or  spring,  merely  by  the  expansion  of 
the  gum,  when  under  the  influence  of  the  heat  evolved  in  the 
interior  of  the  meatus  auditorius.  I  found  it  necessary,  be- 
sides, to  give  to  these  trumpets  a  somewhat  inclined  conical 
form,  and  to  cover  their  internal  surface  with  a  coat  of  imper- 
ishable varnish  of  flesh  colour.  The  Sieur  Laserre  (a  skilful 
manufacturer  of  gum  elastic  instruments  at  Paris)  has  succeeded 
in  constructing  this  species  of  instrument,  after  the  pattern  I 
had  given  him  for  it;  after  which  I  tried  it,  with  complete 
success,  for  the  first  time  in  the  person  of  M.  de  P.  This 
individual,  about  65  years  of  age,  had  been  for  the  last  fifteen 
years  in  a  state  of  complete  deafness.  It  was  quite  evident 
that  in  his  case  his  deafness  had  been  occasioned  by  the  loss 
of  the  greater  portion  of  the  molar  teeth  of  the  corresponding 
side  of  the  jaw  bones  in  which  the  damp  and  marshy  climate 
of  Belgium  had  induced  a  necrosis:  the  incisor  and  canine  teeth 
which  had  not  been  destroyed  by  caries,  had  been  worn  in 
consequence  of  the  more  immediate  friction  and  of  the  upper 
and  lower  maxillae  riding  upon  one  another.  The  inferior 
maxilla  had  been  drawn  upwards  and  backwards  b^T-  degrees, 
and  its  condyles  had,  graduall}^,  and  in  the  same  direction, 
depressed  the  inferior  and  anterior  parietes  of  the  meatus  ex- 
ternus  of  both  ears,  so  that  their  orifice  stood  no  lono-er  in  the 
proper  relation  to  the  extremity  of  the  concha  of  the  ear:  it 


Of  Lesions  of  the  Eai\  257 

was,  on  the  contrary,  in  the  fossa  navicularis  which  is  situated 
before  the  meatus  that  the  rays  of  sound  were  lost,  and  that 
their  being  gathered  upon  the  tympanum  was  frustrated. 

Such  was  the  cause  of  deafness  of  M.  de  P.  Small  trumpets 
constructed  of  gum  elastic,  painted  and  varnished,  remedied 
this  defect  completely,  and  restored  to  him  his  auditive  func- 
tions, so  that  he  could  now  hear  most  distinctly  all  that  was 
spoken  near  him  in  the  usual  tone  of  conversation,  whilst 
without  them  he  never  could  understand  a  single  word,  except 
by  crying  out  loudly  into  the  funnel  of  his  ear. 

This  cause  of  deafness  is  no  doubt  much  more  common  than 
is  generally  suspected,  and  I  have  reason  to  believe  will  often 
be  found  to  prevail  in  invalids  wounded  on  the  jaw  bones. 
The  following  fact  confirms  this  notion  in  some  measure,  and 
as  the  person  had  been  dressed  on  the  field  of  battle  by  myself, 
and  as  I  was  enabled  afterwards  to  conduct  the  treatment 
myself  for  a  long  time,  which  his  wound  required,  I  had  an 
opportunity  to  prove  all  my  conjectures  on  the  modus  ope- 
randi of  this  cause. 

M,  Schmidt,  a  lieutenant  of  the  first  regiment  of  mounted 
grenadiers  of  the  guard,  aged  48  years,  had,  on  June  18th,  1815, 
been  struck  on  the  left  cheek  by  a  grape-shot  in  such  a  manner 
that  the  biscayan,  after  having  disorganized  the  left  commis- 
sure of  the  lips,  lacerated  the  corresponding  portion  of  the 
tono^ue  and  a  portion  of  the  soft  parts  of  the  mouth,  had,  be- 
sides all  the  molar  teeth,  carried  off  also  the  alveolar  margin  of 
the  upper  maxillary  bone  and  that  of  the  jaw,  and  shattered 
the  coronoid  process  of  the  latter,  and  finally  passed  through 
the  parotid  gland,  and  that  portion  of  the  integuments  by 
which  it  is  covered.  As  this  wound  was  of  a  very  serious  and 
complicated  nature,  1  was  compelled  to  dress  the  wounded 
officer  in  the  melee  almost  of  the  disastrous  battle  of  Mont- 
Saint-Jean,  where  a  few  moments  later  I  was  myself  severely 
wounded  and  taken  prisoner.  The  wounds  of  the  cheek  and 
tongue  were  rendered  simple  by  suitable  incisions  and  exci- 
sions, and  the  edges  of  the  wounded  parietes  of  the  mouth 
were  drawn  together  by  sutures;  but  the  injury  in  the  region 
of  the  parotid,  having  from  time  to  time  discharged  numerous 
2  H 


258  Of  Lesions  of  the  Ear. 

fragments,  remained  a  fistulous  sore  for  a  long  time  and  was 
extremely  difficult  to  heal.  During  the  process  of  re-union 
and  cicatrization  of  the  soft  and  the  solid  parts,  the  condyle  of 
the  jaw  of  the  same  side  had  become  drawn  up  and  fallen 
backwards  to  such  an  extent  that  the  inferior  and  anterior 
walls  of  the  meatus  externus  had  become  so  far  depressed  that 
the  orifice  of  the  meatus  had  been  completely  closed  up,  and 
that  therefore  this  officer  had  lost  his  hearing  entirely  on 
that  side:  however,  the  functions  of  hearing  were  instantly 
restored  by  a  trumpet  introduced  into  the  meatus  auditorius 
(an  experiment  easily  to  be  accomplished  with  a  playing 
card). 

When  the  trumpets  are  properly  fixed,  they  are  with  diffi- 
culty distinguished  from  the  concha  of  the  ear.  In  order  to 
accommodate  the  margin  of  their  expanded  surface  to  the  folds 
of  the  ear  exactly,  it  will  be  proper  to  cause  a  mould  of  the 
ear  of  the  deaf  person  to  be  made,  upon  which  the  trumpet 
should  be  constructed,  because  the  ears  of  every  individual 
have  a  peculiar  formation.  They  may  be  taken  out  in  the 
evening,  and  be  replaced  in  the  morning,  always  taking  care, 
if  the  person  should  have  occasion  for  two  trumpets,  not  to 
confound  the  instrument  belonging  to  one  ear  with  that  of  the 
other.  When  once  fixed,  they  are  immovable  for  the  reasons 
already  assigned.  Besides,  these  newly  invented  acoustic 
trumpets  might  be  used  with  the  same  advantage  for  every 
species  of  deafness  which  is  supposed  to  be  the  result  of 
asthenia  of  the  membrana  tympani.  The  precaution  only 
should  be  taken  not  to  leave  the  stem  of  the  funnel  (entonnoir) 
too  long,  lest  it  might  come  in  contact  with  the  membrane 
itself. 

Some  not  less  singular  cures  of  certain  cases  of  deafness, 
pronounced  incurable,  will  be  found  also  in  my  article  on 
moxa.  These  cures  have  been  more  particularly  accomplished 
by  means  of  the  Egyptian  and  Chinese  moxas,  prepared  and 
applied  with  such  modifications,  as  the  nature  of  the  affection, 
the  sex  and  the  age  of  the  patients  seemed  to  require. 

We  could,  moreover,  make  some  suggestions,  not  altogether 
useless,  on  the  accidental  perforation  of  the  tympanum  and  its 


Of  Lesions  nf  I Iif  Ear.  259 

results,  as  well  as  upon  that  whirh  art,  under  certain  circum- 
stances, may  have  recourse  to;  but  these  kinds  of  lesions  are 
described  at  full  length  in  every  classical  work,  or  in  the 
writings  which  treat  exclusively  on  the  diseases  of  the  ear. 
We  may,  however,  cursorily  observe  that  the  rupture  of  the 
tympanum,  although  it  may  be  complete  and  occasioned  by  a 
powerful  rush  of  air,  or  by  the  shock  of  some  mechanical 
cause,  is  not  invariably  followed  by  incurable  deafness.  We 
have  seen  several  individuals  in  whom  this  perforation  had 
actually  occurred,  and  who,  nevertheless,  after  having  been 
deprived,  for  a  longer  or  shorter  space  of  time,  of  their  audi- 
tory faculties,  recovered  them  entirely  and  as  perfectly  as  they 
were  before  the  occurrence  of  the  accident.  It  is  probable 
that  nature  in  this  instance  causes  in  the  progress  of  time  the 
opening  to  heal,  which,  however  simple,  or  complicated  by  loss 
of  substance,  had  been  made  into  the  tympanum;  it  causes  it  to 
heal,  we  may  suppose,  by  means  of  a  concentric  development  of 
the  small  blood  vessels  which  constitute  the  organic  laminae 
of  this  membrane,  and  it  is,  moreover,  probable  that  these 
vessels,  by  subsequently  anastomosing  among  themselves,  form 
an  uniform  and  accurate  cicatrix  which  restores  to  this  tympa- 
num its  appropriate  qualifications.  And  these  results  are  the 
more  likely  to  occur,  as  the  solutions  of  continuity  which 
changed  the  serous  or  mucous  tissues,  promptly  disappear 
under  the  influence  of  cicatrices,  being  so  completely  formed 
upon  them  that  the  smallest  vestige  of  these  solutions  could 
afterwards  be  no  longer  perceived.  This  new  organization 
will  be  still  better  understood  when  we  consider  that  nature 
herself  contrived  to  transfer  the  properties  of  the  membrana 
tympani,  entirely  destroyed  as  it  was,  to  that  portion  of  the 
dermis,  which,  in  one  of  the  cases  above  referred  to,  formed 
the  covering  of  the  meatus  auditorius  externus. 

We  could  relate  several  cases,  corroborating  the  truth  of 
these  assertions;  but  we  will  restrict  ourselves  to  the  following 
fact.  M.  Mazelle,  one  of  the  captains  of  the  18th  dcmi- 
brigade,  being  the  first  at  the  head  of  a  company  of  grenadiers 
who  scaled  the  tower  of  Saint-Jean-d'Acre,  in  Syria,  where  a 
breach  had  been  made  to  force  a  passage  into  that  place,  had 


260  Of  Lesions  of  the  Ear. 

been  thrown  down  in  consequence  of  the  explosion  of  some 
Greek  fire  and  other  combustible  materials,  and  was  pitched 
into  the  moat  of  the  tower.  Besides  other  serious  injuries 
which  he  sustained  from  so  tremendous  a  fall  from  a  height  of 
upwards  of  thirty  feet,  he  had  both  tympana  broken,  and  was 
in  an  instant  totally  deprived  of  hearing.  In  this  condition 
he  remained  for  about  ten  or  twelve  years;  nevertheless, 
after  that  period  the  functions  of  hearing  gradually  became 
restored,  and  he  finally  recovered  that  faculty  to  such  a  degree 
that  he  could  resume  and  perform  all  the  military  duties  of  his 
particular  military  grade  with  the  same  precision  as  before  the 
accident. 

However,  in  a  majority  of  cases,  the  perforation  of  the  tym- 
panum by  means  of  a  surgical  instrument,  instead  of  reinstating 
the  auditory  functions,  as  is  the  operator's  intention,  annihilates 
them  completely;  while  in  some  instances  and  for  the  same 
reasons  which  we  have  stated  above,  they  will  in  the  course  of 
time  be  restored  of  their  own  accord.  Upon  the  whole,  we 
believe  it  to  be  a  difiicult  matter  to  show  precisely  and  in  any 
particular  case  the  efiicacy  of  such  an  operation. 

Previously  to  our  concluding  this  article,  we  shall  indulge  in 
one  simple  remark  more  on  the  perforation  of  the  lobe  of  the 
ear  for  the  purpose  of  suspending  ear-rings  by  it.  In  the  first 
place  it  is  proper  to  perform  this  operation  with  a  small  gold 
needle,  edged  on  both  sides  of  its  point,  similar  to  that  of  the 
suture  needle;  but  while  the  point  of  the  needle  is  yet  retained 
within  the  opening,  we  should  be  particular  how  we  pass  the 
wire  of  lead,  which  is  to  prepare  it  for  the  reception  of  the 
rings  that  are  to  be  suspended,  because  a  galvanic  sensation  is 
its  immediate  consequence,  which  attacks  in  a  singular  manner 
the  nervous  system  of  children  or  other  delicate  persons,  and 
may  possibly  throw  them  into  convulsions,  of  which  we  have 
seen  two  instances.  It  will,  therefore,  be  much  better  to  re- 
place this  needle  by  some  metallic  wire  of  very  close  texture 
and  of  the  same  material  as  the  needle  itself.  With  these  pre- 
cautions all  the  like  accidents  may  be  prevented. 


Diseases  of  the  Eye.  261 

2.   Of  some  Diseases  of  the  Eyes. 

We  shall  in  this  article  dwell  on  the  changes  of  structure  of 
both  the  auxiliary  and  essential  parts  of  the  visual  organ,  which, 
having  exhibited  singular  phenomena,  had  fallen  under  our  own 
personal  notice;  and  we,  moreover,  reserve  to  ourselves  the 
privilege  of  republishing  in  the  description  of  the  parts  of  this 
organ  the  remarks  which  we  have  made  on  the  physiological 
anatomy  of  some  amongst  them. 

In  speaking  of  the  solutions  of  continuity  to  which  the  aux- 
iliary parts  of  the  eye  may  become  subject,  we  shall  say  one 
word  only  on  those  which  destroy  the  integrity  of  the  eye- 
brows. When  the  latter  have  been  occasioned  by  pointed  or 
cutting  instruments,  they  may  be  accompanied  by  lesion  of 
some  of  the  branches  of  the  trochlearis  nerve  which  are  fur- 
nished by  the  ophthalmic  of  Willis.  This  circumstance  may 
give  rise  to  pretty  serious  nervous  symptoms,  suspend  the 
functions  of  vision  for  a  longer  or  shorter  time,  or  change 
them  in  proportion  to  the  extent  of  the  injury.  When  this  is 
the  case,  the  injured  nerves  should  be  clearly  divided  and  the 
"wound  itself  be  converted,  as  far  as  may  be  expedient,  into  a 
simple  solution  of  continuity.  The  nervous  symptoms  will 
then  instantly  cease,  and  vision,  which  may  have  been  sus- 
pended or  weakened,  will  be  restored  with  equal  despatch.  A 
few  examples  of  the  efficacy  of  this  mode  of  dressing  will  have 
been  read  in  the  article  on  Tetanus. 

If,  however,  some  branch  of  the  supra-orbital  arteries  has 
been  divided,  it  will  be  best,  after  separating  all  the  nervous 
filaments  from  them,  immediately  to  apply  a  ligature,  because 
mere  pressure  is  often  insufficient  to  stop  the  hemorrhage. 
But,  in  no  instance  whatever,  should  the  eye-brows  be  shaved, 
inasmuch  as  these  hairy  productions,  with  respect  to  their 
growth,  remain  stationary  until  old  age,  and  that  consequently 
months  and  years  will  be  required,  ere  nature  can  entirely  re- 
produce the  deficiency.  If  the  division  of  the  eye-brows  is 
deep  and  extensive,  it  will  be  useful  and  almost  indispensable 
to  have  recourse  to  a  few  stitches  of  the  interrupted  suture,  so 


262  Diseases  of  the  Eye. 

as  to  preserve  the  precise  consolidation  of  these  parts,  and  the 
original  relation  of  the  hair  which  grows  upon  them. 

The  eye-lids  may  be  divided  or  lacerated,  singly  or  both  at 
once,  in  their  whole  diameter  and  in  different  directions,  either 
by  side  arms,  or  by  projectiles  of  greater  or  lesser  size,  or  by 
some  other  offending  cause,  in  such  a  manner  that  the  solu- 
tions of  continuity  resulting  from  the  action  of  these  various 
causes  bear  a  relative  aspect.  In  every  such  case,  immediate 
reunion  is  the  first  indication,  and  if  the  solution  of  continuity 
be  regular  and  uniform,  it  may  be  accomplished  without  any 
further  preparatory  measure.  Where,  however,  their  edges 
should  appear  to  have  been  abraded,  unequal  or  notched,  they 
should  previously  be  cut  smooth  with  a  pair  of  curved  scissors, 
be  converted  thus  into  simple  wounds,  and  an  interrupted  su- 
ture be  employed  to  keep  them  in  exact  apposition  and  to 
restore  the  eye-lids  to  their  primitive  or  normal  conformation. 
Any  loss  of  substance  which  may  have  occurred  in  their  thick- 
ness, especially  when  the  wounds  are  of  a  recent  date,  should 
be  at  once  unhesitatingly  supplied  by  a  reunion  of  parts,  for 
the  inconveniences  which  are  liable  to  result  from  a  retraction 
of  these  loose  shreds  suffer  no  comparison  with  those  which 
their  chafing  might  possibly  produce. 

No  apprehension  need  be  entertained  on  account  of  the  pass- 
age of  the  needle  through  the  tarsal  cartilages,  which,  like  all 
the  other  tissues  of  the  same  genus,  are  not  susceptible  of 
inflammation;  but  care  should  be  taken,  when  the  suture  is 
employed,  to  embrace  within  it  a  larger  portion  of  the  parts 
exterior  to  the  globe  of  the  eye  than  of  their  inside  surface,  so 
as  to  prevent  the  retroversion  of  the  eye-lid;  but  above  all,  the 
eye-lashes  and  the  margin  of  these  membraneous  coverings 
should  be  fixed  in  their  precise  situation.  Care  also  should  be 
taken,  when  the  solution  of  continuity  is  in  the  vicinity  of  the 
puncta  lachrymalia,  that  the  lachrymal  ducts  which  arise  there, 
are  not  included  in  the  suture.  This  dressing  should  next  be 
supported  by  immobility  of  the  parts,  by  an  appropriate  band- 
age and  rest.  It  will  be  proper  to  keep  the  internal  surface  of 
the  injured  eye-lids  moist  with  a  few  drops  of  the  oil  of  sweet 
almonds,  in  order  to  prevent  the  formation  of  adhesions  to  the 


Diseases  of  the  Eye.  263 

corresponding  point  of  the  ocular  conjunctiva.  We  are  pos- 
sessed of  several  examples  of  various  injuries  of  these  parts 
which  by  the  measures  above  described  have  been  treated 
with  unhoped  for  success. 

Some  diseases  of  the  conjunctiva,  having  very  frequently 
come  under  my  notice,  have  directed  my  attention  particularly 
to  the  anatomical  structure  of  this  membrane;  I  deem  it  my 
duty,  therefore,  to  commence  by  stating  my  views  on  the  latter 
subject. 

The  membrana  conjunctiva  consists  of  an  extremely  thin 
and  very  extensible  cellular  texture,  which  is  formed  by  a  net 
work  of  venous  and  arterial  vessels,  so  numerous  and  so  closely 
connected  that  fine  injections  scarcely  leave  a  space  between 
them.  But,  according  to  the  observations  of  Prochaska,  as 
well  as  from  my  own  researches,  these  vessels  differ  essentially 
from  those  forming  that  part  of  the  membrane  which  lines  the 
internal  surface  of  the  eye-lids  as  far  as  the  point  of  connexion 
with  the  globe  of  the  eye,  and  from  those  which  compose  the 
covering  of  the  convex  and  anterior  surface  of  this  globe.  In 
the  former  portion,  which  I  shall  call  the  conjunctiva  palpe- 
bralis,  the  texture  of  which  appears  to  me  to  be  analogous  to 
that  of  mucous  membranes,  and  to  have  in  common  with  them 
all  their  properties,  the  blood-vessels  are  arranged  in  such  a 
way  that  they  nearly  all  run  parallel  in  the  direction  of  the 
eye-lid,  forming  thus  concentric  curves,  more  or  less  approxi- 
mating one  another,  and  being  interlaced  by  very  slender  ner- 
vous filaments.  The  venous  apparatus  appears  to  us  to  lie  not 
so  deep  as  the  arterial,  and  seems  to  form  a  sort  of  villous  tissue, 
if  we  may  say  so,  on  the  surface  which  is  in  contact  with  the 
globe  of  the  eye.  It  is  no  doubt  this  villous  texture  which  by 
exhalation  conveys  a  mucous  humour  to  the  interior  of  the  eye- 
lids, with  which  the  tears  mix  which  are  poured  out  by  the 
excretory  canals  of  the  lachrymal  gland  within  the  internal 
surface  of  this  palpebral  conjunctiva,  and  in  the  direction  of 
the  lesser  angle  of  the  eye.  The  characteristic  features  of  this 
portion  of  the  conjunctiva  are,  moreover,  methinks,  attested 
by  the  pathological  affections  which  from  preference,  as  it  were, 
are  disposed  lo  attack  it:  for,  it  is  the  exclusive  seat  almost  of 


264  Diseases  of  the  Eye. 

all  the  catarrhal,  symptomatic  or  idiopathic  opthalmiae,  and 
these  changes  may,  indeed,  run  to  a  very  high  extent  before 
the  ocular  portion  of  the  conjunctiva  participates  in  them,  at 
least  in  many  cases. 

Owing  to  the  effects  of  the  inflammation  by  which  it  has 
been  attacked,  its  texture  becomes  susceptible  of  a  still  greater 
expansion,  and  is  capable  of  producing  a  tumour  so  much  pro- 
jecting outwardly  that  it  everts  the  eye-lids  and  forms  an 
enormous  exuberance  in  frontof  the  globe  of  the  eye  by  which 
the  latter  is  covered  completely.  It  is  then  that  the  vessels  of 
which  we  have  spoken  may  be  perceived  in  such  an  injected 
condition  that  it  will  be  impossible  to  plant  the  point  of  a  pin 
into  its  texture  without  wounding  some  of  them. 

Guided  by  this  anatomical  knowledge,  and  after  having  pre- 
viously overcome  the  causes  which  produced  the  eversion  .or 
tumefaction  of  the  palpebral  conjunctiva;  in  fine,  when  the  affec- 
tion has  assumed  a  purely  local  character,  the  remedies  to 
effect  a  cure  consist  in  the  first  place  of  scarifying,  if  necessary, 
these  excrescences  in  a  direction  parallel  with  the  margin  of 
the  eye-lids,  and  afterwards  in  gently  and  uniformly  pressing 
this  vascular  growth  with  the  fingers,  dipped  previously  in 
oil  of  sweet  almonds,  which  may  be  done  without  giving 
much  pain.  The  reduction  which  it  is  desirable  to  ob- 
tain in  this  way,  is  pretty  readily  accomplished,  and  nothing 
else  remains  to  be  done  but  to  reinstate  the  eye-lids  in  their 
primitive  relation  and  to  keep  them  in  that  position  by  means 
of  a  band  applied  carefully  and  sufficiently  tight.  By  this 
treatment  I  have  constantly  succeeded  in  many  cases,  where 
I  had  been  obliged  to  put  it  in  practice,  and  I  have  never  been 
under  the  necessity  of  having  recourse  to  excision,  so  much 
extolled  by  the  French  and  English  oculists. 

From  this  general  rule,  however,  is  the  swelling  of  the  con- 
junctiva to  be  excepted,  which  is  apt  to  supervene  after  a  re- 
union of  the  eye-lid  has  been  effected,  as  in  the  case  of  a  wound 
with  or  without  loss  of  substance.  But,  this  is,  in  my  opin- 
ion, the  only  instance  where  the  excision  of  the  membranous 
growth  is  indicated,  and  where  even  it  will  be  indispensable, 
because  of  the  retraction  which  had  taken  place  in  the  eye-lid, 


Diseases  of  the  Eye.  265 

in  consequence  of  the  immediate  reunion  of  the  two  flaps  which 
were  the  efTects  of  the  division.  But,  even  in  that  case, 
instead  of  making  this  excision  across,  as  the  majority  of  oculists 
recommend,  I  propose  to  make  it  in  a  direction  parallel  to 
the  ej-c-lid,  and  to  a  greater  or  lesser  extent,  in  proportion  to 
the  size  of  the  everted  mass  of  this  membrane.  A  pair  of 
scissors,  sloped  or  curved  on  their  flat  side,  is  the  best  in- 
strument for  performing  tiiis  operation.  Frequent  washing  with 
a  mild  solution  of  emetic  tartar,  combined  with  equal  parts  of 
an  aqueous  solution  of  opium,  will  afterwards  be  sufficient  to 
cause  these  incisions  to  cicatrize  and  to  induce  the  engorged 
vessels  of  the  remainder  of  the  membrane  completely  to  retract, 
so  that  the  patient  may  anticipate  a  speedy  recovery. 

The  vessels  of  the  ocular  conjunctiva  are  a  good  deal 
thinner,  and  furnish  a  more  slender  and  closer  texture  which 
appi'oaches  the  serous  character;  they  are  so  arranged,  as  to 
form  a  circuitous  and  concentric  net-work  from  the,  circumfe- 
rence to  the  centre,  and  towards  the  pupil.  Their  arrangement 
otherwise,  in  accordance  with  their  kind,  is  analogous  to  that 
of  the  vessels  of  the  palpebral  conjunctiva.  They  arise  from 
those  which  creep  on  the  surface  of  the  sclerotica,  in  order 
gradually  to  extend  forwai'd  round  the  transparent  cornea, 
where  they  disappear  almost  entirely;  that  is  to  say,  the  colour- 
ing matter  ordinarily  remains  in  the  last  ramuscuJes  which 
connect  themselves  with  this  cornea,  or  penetrate  into  its  sub- 
stance. These  are  the  vessels  which,  in  some  cases  of  ob- 
stinate ophthalmia,  give  rise  to  what  is  denominated  cAemo525. 

When  the  tumefaction  which  occasionally  terminates  by 
completely  concealing  the  transparent  cornea,  has  set  at 
defiance  the  various  indicated  remedies,  such  as  depletory  and 
slightly  repellent  measures,  it  will  then  be  necessary  to  dissect 
it  out  by  piece-meal  in  a  circular  direction,  with  a  pair  of  cur- 
ved scissors  and  a  dissecting  forceps.  Some  remarkable 
phenomena  attend  these  excisions:  the  part  of  the  globe  of  the 
eye  thus  denuded  of  the  ocular  conjunctiva  retains  an  exqui- 
site sensibility,  and  takes  a  very  considerable  time  again  to  be- 
come organized,  or  to  form  the  cuticle  of  cicatrization  which 
may  be  observed  every  where  else  on  the  surface  of  the  body, 
21 


266  Diseases  of  the  Eye. 

Under  these  circumstances  it  is  necessary  to  guard  against  the 
friction  of  the  eye-lids,  which  is  very  painful  and  troublesome, 
by  frequently  bathing  them  with  fresh  oil  of  sweet  almonds, 
mixed  with  a  small  portion  of  distilled  water  of  opium.  We 
have  had  occasion  several  times  to  perform  this  operation,  and 
have  invariably  observed  afterwards  the  same  effects.  It  was, 
moreover,  on  these  occasions  that  we  were  enabled  to  observe 
that  the  blood-vessels  of  the  conjunctiva  reach  not  only  to  the 
centre  of  the  transparent  cornea,  but  that  they  traverse  it 
throughout  its  whole  extent. 

Tliat  part  of  the  conjunctiva  which  surrounds  the  caruncula: 
lachrymales  is,  after  inflammations  to  which  it  has  been  sub- 
ject, likewise  susceptible  of  thickening,  and  of  assuming  even 
the  character  of  a  membranous  and  almost  corneous  texture. 
Very  near  akin  to  the  membrana  nictitans  of  aquatic  birds, 
this  species  of  pterygium  is  pretty  rapidly  developed,  till  it 
has  grown  to  the  size  of  a  lentil;  but  after  this  it  remains 
stationary,  or  its  growth  is  barely  perceptible.  In  this  state, 
it  impedes  the  functions  of  vision  and  the  motions  of  the  eye, 
prevents  the  eye-lids  from  shutting  close  and  keeps  up  a  per- 
petual irritation  in  the  organ  of  sight;  sometimes  even  this 
membranous  growth  spreads  over  the  transparent  cornea  in  a 
crescentic  shape,  by  becoming  somewhat  attenuated,  and 
covers  the  pupillary  region  in  such  a  way  as  to  intercept  the 
passage  of  the  rays  of  light.  It  appears  that  these  growths  are, 
on  the  whole,  rarely  to  be  met  within  our  climates,  but  are  quite 
common  in  Egypt,  where  I  have  seen  them  in  many  indivi- 
duals as  well  as  in  horses.  It  would  be  difficult  to  explain  the 
cause  of  this,  but  they  made  their  appearance  more  especially 
after  acute  and  obstinate  opthalmiae. 

I  have  seen  sometimes  in  Arabian  horses  a  considerable 
number  of  these  horny  curtains  occupy  in  a  short  time  one 
half  of  the  surface  of  the  eye;  two  of  my  own  exhibited  this 
peculiarity.  jNI.  Loir,  a  veterinary  surgeon  of  the  army,  at 
my  request,  extirpated  these  pterygia.  I  have  myself  per- 
formed this  small  operation  on  several  of  our  soldiers.  The 
only  instance  where  it  gave  me  some  trouble  was  on  account 
of  an  excrescence  of  the  same  character  which  M.   Durant, 


Diseases  of  the  Eye.  267 

collector  of  the  myry,  had  had  in  the  right  eye,  ever  since  he 
had  been  attacked,  some  months  before,  with  a  most  severe 
ophthalmia.  This  unguis,  being  of  the  size  of  a  double  lentil, 
occupied  the  large  angle  of  the  eye  entirely,  covered  apart  of 
the  transparent  cornea,  and  had  posteriorly  formed  some  adhe- 
sion with  the  margin  of  the  opaque  cornea,  so  that  in  the  first 
place  it  became  necessary  to  break  up  this  adhesion,  which  I 
accomplished  by  passing  a  small  bistoury  on  a  very  delicate 
grooved  director,  under  this  species  of  adventitious  eye-lid, 
after  which  I  extirpated  it  at  its  root  behind  the  caruncula 
lachrymalis.  Lotions  of  Goulard  water,  with  which  I  com- 
bined a  few  grains  of  alum,  were  sufficient  to  cicatrize  the  small 
wound  of  the  conjunctiva.  I  have  also,  since  our  return  to 
France,  performed  the  same  operation  upon  several  persons 
who  had  brought  this  infirmity  with  them  from  Egypt,  and 
who  were  speedily  cured. 

Before  passing  over  to  the  solutions  of  continuity  which 
concern  the  globe  of  the  eye  in  a  more  direct  manner,  we  will 
point  out  some  lesions  of  the  lachrymal  gland  which  must 
be  of  rare  occurrence,  for  in  the  course  of  our  long  practice 
we  have  had  but  one  opportunity  to  witness  an  instance  of 
them  in  a  private  of  the  young  guard.  This  person,  in  one  of 
the  battles  which  our  armies  fought  in  Old  Castile,  in  Spain, 
had  been  struck  by  a  spent  ball  on  the  receding  angle  of  the 
external  margin  of  the  left  orbit.  One  half  of  this  leaden  pro- 
jectile penetrated  through  the  substance  of  the  lachrymal  gland 
into  the  orbit,  and  was  arrested  in  its  career  upon  the  orbitar 
surface  of  the  malar  bone;  the  other  half  had  made  its  way 
under  the  aponeurosis  of  the  temporal  muscle  from  whence  it 
was  afterwards  easily  extracted.  But,  in  order  to  get  at  the 
former,  it  became  necessary  to  dilate  the  base  of  the  lower  eye- 
lid below  the  commissure,  and  to  remove  the  remnants  of  the 
gland  itself,  together  with  the  ball  alluded  to,  which  had  been 
slightl)Mncrusted  with  bone.  These  wounds  healed  promptly 
without  any  unpleasant  occurrence,  and  to  our  great  surprise 
the  eye  of  the  same  side  was  unhurt;  it  seemed  to  us  to  be  be- 
dewed with  serum  sufficient  for  the  motions  of  the  eye-ball, 
and  was  consequently  exempt  from  ophthalmia. 


268  Diseases  of  the  Eye. 

Could  not,  after  this  specimen,  but  more  especially  where  a 
fistula  lachrymalis  presents  but  few  chances  of  a  cure,  the 
gland  of  that  name  be  extirpated,  as  has  been  proposed  by 
some  authors  (an  operation  which  could  be  done  with  the 
greatest  ease),  the  excessive  secretion  of  tears  be  obviated 
thereby,  and  the  fistula  be  induced  to  disappear? 

In  the  instance  of  the  last  mentioned  afl'ection,  we  will  take 
occasion  to  say  that  the  operations- in  use  prove  nearly  all  in- 
sufficient to  accomplish  a  cure  and  are  not  seldom  attended 
with  danger.  I  have,  in  fact,  come  to  the  conviction  that  the 
tumour  or  fistula  lachrymalis  can  be  the  result  only  of  a  spon- 
taneous morbid  cause,  which  changes  the  structure  of  the  mu- 
cous membrane  of  the  lachrymal  passages,*  and  that,  without 
previously  having  overcome  that  cause,  every  operation  is 
commonly  unsuccessful,  while  in  those  instances  in  which  care 
had  been  taken  to  act  first  upon  this  morbific  principle,  the 
operation  is  attended  with  success,  not  so  much  perhaps  on 
account  of  its  own  intrinsic  value,  but  rather  on  account  of  the 
destruction  of  the  virus.  The  consequences  of  which  the  lat- 
ter is  the  cause,  are  then  suspended,  the  fistula  disappears 
generally  of  its  own  accord,  or  some  few  local  applications  will" 
suffice  to  perform  a  cure.  The  older  writers,  moreover,  and 
some  authors  of  the  last  century,  amongst  whom  Louis  and  Fou- 
bert  are  most  conspicuous,!  had  given  it  as  their  opinion  that  fis- 
tula lachiymalis  was  incapable  of  being  cured  by  any  operation, 
without  having  previously  destroyed,  by  the  employment  of 
depuratory  remedies,  the  morbid  cause  hj  which  it  had  been 
produced:  this  was  particularly  the  opinion  entertained  by 
the  physicians  of  Padua  in  Italy,  during  the  fifteenth  century. 

The  first  surgical  indication  to  be  fulfilled  accordingly  in  the 
case  of  a  lachrymal  tumour,  is  in  our  opinion  to  open  the  sac, 
if  it  contain  any  purulent  matter,  by  a  semi-circular  incision 
below  the  tendon  of  the  eye-lid  and  by  making  some  degree 
of  compression  upon  the  walls  of  the  opened  sac.     And  in 

*  From  ihis  I  except  those  cases  in  which  the  disorder  had  been  occasioned 
by  some  mechanical  cause,  which  happens  very  rarely  and  may  be  readily  dis- 
tinguished. 

t  See,  Les  Mémoires  de  l'Académie  Royale  de  Chirurgie. 


Diseases  of  the  Eye.  269 

order  to  subdue  the  internal  cause  by  which  the  disease  is  kept 
up,  an  alterative  treatment  may  at  the  same  time  be  employed; 
and  inasmuch  as  this  cause  can  frequently  be  referred  to  the 
presence  of  a  varioloid,  syphilitic  or  scrofulous  virus,  mercury 
in  the  shape  of  frictions  upon  the  great  angle  of  the  eye,  as  well 
as  taken  internally,  diaphoretics  and  bitters,  according  to  the 
nature  of  the  virus,  will  by  degrees  cause  the  fistulai  lachry- 
males  resulting  from  it  to  disappear,  provided  they  are  not  too 
inveterate.  If  there  be  symptoms  of  intense  local  inflamma- 
tion present,  this  treatment  should  then  be  preceded  by  the 
application  of  a  few  leeches  to  the  canine  region.  In  confir- 
mation of  these  views  I  might  relate  the  cases  of  five  or  six 
soldiers  who  being  attacked  with  tumours  or  fistulas  lachry- 
males,  extremely  well  marked,  although  not  of  a  chronic 
character,  have  been  cured  in  the  course  of  three,  four  or  five 
months  at  most,  by  means  of  the  various  remedies  above  men- 
tionedc  Concerning  this  subject  see  also  a  notice  inserted  in 
the  Revue  Médicale. 

But  when  the  closing  up  of  the  nasal  canal  is  owing  to  the 
obliteration  of  its  parietes,  or  to  an  induration  of  the  periosteum 
and  of  the  mucous  membrane  which  lines  them,  we  agree  that 
these  means  are  insufiicient,  and  that  under  such  circumstances 
the  flowing  of  the  tears  can  be  re-established  only,  by  introdu- 
cing into  the  obstructed  ducts  a  canula  of  gold  or  silver, 
capable  of  surmounting  these  obstacles,  and  that  afterwards  it 
should  be  suffered  to  remain  there;  or  it  may  be  re-established 
by  perforating  the  os  unguis  with  the  aid  of  a  punch,  so  as  to 
establish  and  preserve,  by  the  formation  of  an  artificial  canal, 
a  direct  communication  with  the  nasal  fossce.  The  introduc- 
tion of  these  canulae,  which  is  more  or  less  painful  and  difficult, 
and  their  presence  in  the  lachrymal  passages,  are  frequently 
accompanied  by  such  serious  inconveniences  that  the  majority 
of  patients  are  little  inclined  to  endure  their  operation;  while, 
on  the  other  hand,  these  conductors  are  scarcely  withdrawn 
from  their  position,  when  the  fistula  returns  with  all  its  disa- 
greeable consequences.  We  have  contrived  a  remedy  very 
simple  in  its  operation,  which  dispenses  entirely  with  the  em- 
ployment of  these  foreign  bodies,   and  which  renders   this 


270  Diseases  of  the  Eye. 

complaint  quite  bearable  and  invisible  to  public  notice.  It 
consists  in  the  introduction  into  the  fistulous  hole  of  the  lach- 
rymal sac,  or  into  that  made  by  the  bistoury,  of  a  piece  of  cat- 
gut three  or  four  lines  long,  the  external  extremity  of  which 
is  fixed  to  a  patch  of  English  taffeta.  The  tears  run  off  by 
means  of  this  small  conductor,  and  the  patient  need  not  give 
himself  any  further  trouble  than  to  sponge  and  dry  with  his 
handkerchief  the  aqueous  fluids  which  accumulate  slowly  under 
the  patch  of  silk.  This  method  has  perfectly  succeeded  with 
me  in  several  instances,  but  I  shall  limit  myself  to  the  very 
brief  relation  of  the  following  case. 

Mdme.  Sellier,  a  wood-seller  at  Gros  Caillou,  had  been  for 
several  years  aflSicted  with  a  fistula  lachrymalis  of  the  left  eye, 
which,  along  the  track  of  the  fistulous  opening,  had  frequently 
become  complicated  with  erysipelas  and  abscesses  in  the  region 
of  the  lachrymal  sac.  This  woman  had  already  undergone 
two  operations,  the  one  resulting  in  the  passage  of  a  string  or 
seton  into  the  nasal  canal,  which  had  not  been  attended  by  any 
success  whatever,  although  the  remedy  had  been  persevered 
in  for  seven  or  eight  months;  the  other,  consisting  in  the  in- 
troduction of  a  gold  canula,  had  been  productive  of  nervous 
symptoms  of  so  serious  a  nature  that  it  had  to  be  withdrawn 
before  the  expiration  of  the  ninth  day.  The  patient  had  at 
length  been  abandoned  to  the  resources  of  nature  alone.  Be- 
ing called  to  her  assistance  on  the  occasion  of  a  new  phlegmo- 
nous abscess  having  supervened  at  the  great  angle  of  the  eye, 
we  undertook  her  treatment.  Having  made  the  incision 
which  we  have  mentioned  above,  cleansed  the  purulent  recep- 
tacle and  the  lachrymal  sac  by  means  of  alkaline  injections, 
and  prescribed  for  the  patient  an  alterative  course  of  medicine 
internally,  I  placed  the  cat-gut  into  the  little  wound  by  fasten- 
ing its  external  extremity  to  a  patch  of  gummied  taffeta,  and 
repeated  this  small  operation  myself  for  the  first  eight  days. 
The  woman  became,  at  last,  accustomed  to  this  daily  dressing, 
and  has  continued  it  with  so  much  benefit  that  she  experiences 
now  no  other  inconvenience  from  it  than  that  of  wiping  away 
with  her  handkerchief,  three  or  four  times  daily,  the  few  tears 
which  collect  beneath  the  patch,  which  is  scarcely  observed. 


Diseases  of  the  Eye.  271 

The  eye  of  this  individual  is  as  clean  and  clear  as  that  of  the 
other  side.  In  this  satisfactory  condition  she  has  been  exam- 
ined by  some  of  the  foreign  practitioners  who  usually  attend 
my  clinical  lectures. 

The  alterations  of  the  eye-ball  include  two  classes  of  dis- 
orders. The  first  consists  in  the  contusion,  or  the  direct  or 
indirect  concussion  which  the  parts  of  this  organ  are  doomed 
to  sustain  from  extraneous  bodies.  The  second  comprehends 
the  solutions  of  continuity  which  mechanical  substances  of 
whatever  shape  or  character  may  inflict  upon  the  same  parts. 
Whether  encroaching  upon  the  integrity  of  one  or  both  corneas 
at  the  same  time;  or  whether  they  are  complicated  by  divisions 
or  lacerations  of  the  internal  membranes,  these  solutions  of 
continuity  may  be  followed  by  the  discharge  of  the  crys- 
talline lens  and  the  vitreous  humour.  This  last  circumstance 
can  equally  take  place  upon  the  occasion  of  the  first  species  of 
alterations,  when  contusions  may  have  been  conveyed  with 
sufficient  violence  to  induce  a  rupture  or  laceration  of  the 
different  coats  of  the  globe  of  the  eye. 

We  believe  that,  with  respect  to  these  diseases,  we  need  not 
enter  upon  a  theoretical  description  of  them:  the  account  of 
the  cases  to  be  given  in  succession  will  be  sufficient  to  make 
known  the  symptoms  and  to  point  out  the  proper  course  to  be 
pursued  for  their  cure. 

First  Observation.  M.  Magny,  chief  officer  of  a  brigade  of 
the  2d  regiment  of  light  infantry,  was,  at  the  battle  of  Aboukir, 
struck  by  a  ball  which  grazed  the  external  side  of  the  right 
orbit,  and  without  wounding  the  skin,  produced  so  violent  a 
contusion  in  the  eye  of  that  side,  that  its  nervous  membrane 
lost  the  power  of  sensation,  and  it  was  all  at  once  deprived  of 
vision.  He  immediately  felt  à  severe  and  heavy  pain  at  the 
bottom  of  the  orbit,  accompanied  by  a  sense  of  weight  in  the 
head,  by  effusion  of  blood  into  the  cavities  of  the  e^ye,  and  by 
engorgement  of  the  conjunctiva.  For  the  first  fortnight  he 
had  been  attended  by  the  surgeon-major  of  his  brigade. 

When  I  saw  him  for  the  first  time,  the  engorgement  of  tlie 
external  membranes  of  the  eye  had  disappeared;  but  through 
the  transparent  cornea  a  pretty  large  quantity  of  blood  in  a  fluid 


272  -  Diseases  of  the  Eye. 

state  could  be  observed,  filling  up  three-quarters  of  the  ante- 
rior chamber.  The  patient  experienced  already  lancinating 
pains  in  the  centre  of  the  eye  and  frequent  headach.  The 
injured  eye  was  sensibly  larger  than  that  of  the  sound  side; 
and  he  was,  moreover,  troubled  with  insomnia  and  restless- 
ness, all  which  made  me  apprehend  the  development  of  a 
carcinomatous  affection.  My  apprehension  was  the  more 
founded,  as,  subsequently  to  a  similar  accident  which  had  oc- 
curred to  an  officer  of  the  75tii  demi-brigade,  the  eye  of  the 
latter  had  been  attacked  with  all  the  symptoms  of  cancer, 
which  could  be  removed  only  by  the  loss  of  this  organ,  and  a 
long  and  regulated  treatment.  I  am,  in  fact,  pursuaded  that 
any  quantity  of  blood,  extravasated  from  its  proper  vessels, 
cannot  remain  for  a  length  of  time  confined  in  the  sensible 
parts  of  the  organs,  without  entailing  upon  them  a  degree  of 
irritation  more  or  less  intense  and  accompanied  by  unpleasant 
symptoms,  as  we  have  had  occasion  to  remark  upon  other 
occasions. 

After  having,  in  the  case  of  M.  Magny,  employed  local  de- 
pletion, topical  applications  and  refrigerants,  I  deemed  it 
indispensable  to  make  an  opening  for  the  discharge  of  the 
blood  effused  into  the  cavities  of  the  eye.  I  took  the  bistoury 
of  Lafaye,  as  in  the  operation  for  cataract,  and  made  an  oblique 
section  from  below  inwards  into  the  transparent  cornea. 
About  one  drachm  of  fluid  and  blackish  looking  blood  was 
discharo-ed.  The  issue  of  this  foreio-n  substance  exhibited  to 
me  the  iris  which  appeared  to  perform  some  slight  motion, 
and  the  patient  saw  the  light  forthwith,  but  without  being  en- 
abled to  distinguish  any  objects.  Every  other  symptom  was 
dispersed,  the  eye  became  unloaded,  and  the  cornea  cicatrized 
without  any  opacity  or  deformity  of  consequence.  This  supe- 
rior officer,  on  his  return  to  France,  where  he  made  use  of 
proper  collyria,  began  to  perceive  the  objects  which  he  subse- 
quently was  enabled  to  distinguish.  One  of  the  aids  of 
General  Robin  having  met  with  an  accident  of  this  kind,  oc- 
casioned by  a  similar  cause  and  presenting  the  same  phenomena, 
had  an  operation  performed  on  himself,  attended  by  a  precisely 
analogous  result. 


Diseases  of  the  Eye.  273 

Second  Observation.  If  the  shock  directed  against  the 
ball  of  the  eye  has  not  been  of  too  much  force;  or  if  it 
occurs  in  an  oblique  direction,  the  loss  of  sight  can  take  place 
only  for  a  short  time.  Etienne  Ripert,  a  private  of  the  6th 
regiment  of  infantry  of  the  guard,  entered  the  hospital  of 
Gros-Caillou  on  the  20th  August  1S21,  on  account  of  a  blow 
which,  three  days  previously,  while  at  play  with  one  of  his 
comrades,  he  had  received  in  the  right  orbit  with  a  green 
switch  of  the  size  of  a  goose  quill.  The  switch  having  been 
directed  obliquely  against  the  ball  of  the  eye,  had  lacerated 
the  ocular  conjunctiva  and  made  its  way  as  far  as  the  internal 
half  of  the  orbit.  The  consequence  of  this  was  the  instantane- 
ous loss  of  vision  of  that  side,  which  no  doubt  had  been  occa- 
sioned by  the  concussion  of  the  ball  and  the  shock  sustained 
by  the  retina.  The  loss  of  vision  still  continued  at  the  time 
of  the  patient's  admission  into  the  hospital:  the  iris  did  not 
contract,  which  led  me  to  suspect  the  lesion  of  the  nasal  branch 
of  the  ophthalmic  nerve. 

I  ordered  scarified  cups  at  once  to  be  applied  to  the  temples 
and  to  the  nape  of  the  neck,  some  leeches  to  the  base  of  the  orbit, 
and  the  feet  to  be  put  into  mustard  baths.  At  the  end  of  the 
eighth  day  from  the  employment  of  these  remedies,  the  pains 
had  completely  subsided,  and  vision,  although  feebly,  began  to 
.return.  In  order  to  induce  a  more  prompt  and  more  perfect  re- 
establishment  of  this  function,  I  deemed  it  expedient  to  direct 
the  application  of  two  moxas  to  the  posterior  part  of  the  head, 
below  the  occipital  protuberances,  and  several  other  small 
Chinese  moxas  to  the  base  and  near  the  internal  angle  of  the 
lower  eye-lid.  These  revulsives  pi'oduced  the  desired  effects; 
vision  soon  recovered  its  full  strength  and  the  activity  which 
it  had  possessed  before  the  accident. 

Third  Observation.  Dreux,  a  mounted  chasseur  of  the  ex- 
guard,  received  in  single  combat  a  sabre  cut  which  pierced  his 
right  eye:  a  transverse  wound  of  the  cornea  of  several  lines  in 
diameter,  with  loss  of  substance  of  a  small  part  of  this  membrane, 
was  the  consequence  of  this  accident,  which,  according  to  the 
statement  of  the  patient,  had  been  immediately  succeeded  by 
the  evacuation  of  some  thick  and  limpid  fluid,  and  by  a  sinking 
2  K 


274  Diseases  of  the  Eye. 

of  the  ball  of  the  eye.  He  was  deprived  of  vision,  suffered 
violent  pain  and  had  at  first  some  vomiting.  He  had  given 
up  every  hope  of  ever  recovering  the  use  of  his  eye  again, 
but,  to  my  great  surprise,  the  globe  had  gradually  resumed  its 
original  form  and  natural  size,  so  that  there  could  be  no  doubt 
that  the  vitreous  humour,  a  certain  quantity  of  which  having 
actually  escaped,  had  been  reproduced.  The  edges  of  the 
wound  approximated  each  other  and  contracted  so  slight  an 
adhesion  that  their  cicatrix  continued  to  be  rather  depressed 
without  being  opaque.  The  iris  which  had  been  wounded, 
resumed  its  motions,  while  the  pupil  opposite  the  cicatrix  re- 
mained indented.  This  soldier,  previous  to  his  leaving  the 
hospital,  could  see  the  light,  and  a  few  months  later  he  was 
enabled  to  distinguish  colours  and  conspicuous  objects. 

Fourth  Observation.  In  case  of  wounds  of  the  cornea, 
accompanied  with  the  escape  of  the  aqueous  membrane  or  iris, 
I  shall  point  out  a  method  of  proceeding  about  which  authors 
have  said  nothing,  and  which  had  been  suggested  to  me  by 
an  unfortunate  occurrence  which  happened  to  my  daughter, 
Clémence-Isaure.  When  the  hernia  of  these  membranes  has 
resulted  from  an  injury  of  the  cornea,  occasioned  by  some 
wounding  substance,  it  should  be  reduced  at  once  with  the 
utmost  gentleness,  by  means  of  a  blunt  pointed  golden  style; 
every  other  metal,  w^hen  applied  to  these  delicate  and  exceed- 
ino-ly  sensible  parts,  being  liable  to  produce  galvanic  impress- 
ions highly  unpleasant  to  the  patient.  The  membranes 
resume  their  original  position,  and  the  deformity,  and  disturb- 
ance of  the  visual  functions  may  be  thus  prevented  which 
otherwise  would  not  fail  to  occur,  if  the  staphyloma  were  left 
to  the  resources  of  nature  alone. 

This  young  lady,  being  then  about  seven  years  old,  while 
engaged  in  cutting  the  bread  for  her  breakfast  into  pieces, 
suddenly  felt  her  right  eye  pricked  by  a  small  piece  of  the  crust 
of  her  bread.  Frightened  by  it,  she  rashly  carried  her  hand 
to  the  eye  in  order  to  seize  this  foreign  substance;  but,  holding 
the  knife  in  the  same  hand,  the  motion  of  which  had  forestalled, 
as  it  were,  her  will,  instead  of  the  finger  she  plunged  the  point 
of  this  instrument,  recently  sharpened  as  it  was,  into  the  centre 


Diseases  of  the  Eye.  275 

of  the  cornea,  whereby  the  latter  was  cut  obliquely  along  its 
whole  external  half,  forming  thus  a  wound  of  three  or  four 
lines  in  length.  A  portion  of  the  aqueous  membrane  and 
even  of  the  iris  presented  at  the  opening  and  constituted  a 
hernia  of  the  thickness  of  a  pea.  The  aqueous  humour  had 
escaped;  the  eye  had  sunk  in,  and  vision  was  totally  suspended. 
I  entered  very  nearly  at  that  moment;  the  screams  of  the  child 
and  the  uneasiness  of  her  mother  informed  me  beforehand  of 
the  occurrence  of  an  accident.  I  had  courage  and  coolness 
enough  left  to  render  assistance.  Having  placed  the  little 
patient  in  a  convenient  position,  I  returned,  with  my  golden 
style,  the  membranous  parts  which  formed  the  staphyloma, 
and  endeavoured  to  replace  them  in  their  former  situation. 
An  entire  reduction  being  thus  obtained,  I  lowered  the  eye-lid 
and  kept  the  eye  closed  by  means  of  compresses  soaked  in 
Goulard  water,  strengthened  by  a  few  drops  of  spirits  of  cam- 
phor, and  retained  by  an  appropriate  bandage.  Several  pedi- 
luvia,  cooling  drinks,  diet  and  absolute  rest  in  a  dark  chamber 
sufficed  to  accomplish  a  perfect  cure  in  the  space  of  a  very  few 
days.  The  sight  of  this  eye  had  not  been  changed,  and  the 
cicatrix  of  the  cornea  is  imperceptible. 

An  occurrence  of  the  same  kind,  which  certainly  had  not  been 
treated  in  a  sufficiently  prompt  and  energetic  manner,  was  far 
from  being  attended  by  an  equally  happy  result,  for  the  sight 
of  the  injured  eye  had  been  completely  lost.  We  shall  relate 
this  fact  literally  as  we  have  read  it. 

"Nicolas  Lefevre,  born  at  Paris  July  2d  1544,  commenced 
his  studies  at  the  college  of  La  Marche;  where  in  his  earliest 
youth  he  was  near  being  destroyed  by  an  accident  as  remark- 
able as  it  was  distressing.  While  engaged  in  making  a  pen, 
some  of  the  clippings  cut  off  by  the  pen-knife  flew  into  his 
right  eye;  where,  in  the  act  of  carrying  his  hand  to  it  at  that 
moment,  because  of  the  violent  pain  which  he  felt  there,  he 
carried  with  it  also  the  point  of  the  knife,  which  rent  the  eye. 
In  consequence  of  this  he  was  taken  dangerously  ill;  and  after 
he  had  been  restored  to  health,  it  appeared  to  him  as  if  the 
powers  of  the  lost  eye  had  been  transferred   entirely  to  the 


276  Diseases  of  the  Eye. 

other,  with  which  he  could  see  as  plainly  as  he  before  could 
with  both."     (Le  P.  Niceron.) 

Fifth  Observation.  The  great  majority  of  the  phenomena 
of  which  we  have  spoken  in  the  preceding  cases,  and  among 
others  the  reproduction  of  the  vitreous  humour,  will  doubtless 
derive  still  more  decided  proof  from  the  highly  interesting 
case  which  I  am  now  about  to  relate. 

Peter  Pécheur,  a  serjeant  of  the  fifth  regiment  of  the  royal 
guards,  being  hurried  in  leaving  his  apartment,  on  March  20th 
182 1,  at  six  o'clock  in  the  morning,  in  order  to  attend  the 
roll-call,  inadvertently  fell  upon  a  heap  of  musket  locks,  lying 
in  the  middle  of  his  room.  The  head  having  first  struck 
against  them,  and  his  left  03^6  having  come  in  contact  with  one 
of  the  isolated  caps,  projecting  from  this  confused  mass  of  ar- 
mour, the  ball  of  this  organ  had  been  rent  by  the  point  of  that 
piece  of  iron  and  was  emptied  of  nearly  all  its  contents.  In 
his  hand,  which  he  mechanically  carried  towards  the  eye,  he 
found  a  glairy  substance,  within  which  he  observed  another 
body  of  a  white  colour  and  round  shape,  like  a  lentil  (which 
was  the  crystalline  lens,  floating  no  doubt  in  a  certain  portion 
of  the  aqueous  and  vitreous  humours). 

Having  washed  his  eye  with  cold  water,  and  covered  it  with 
a  cloth,  he  repaired  to  the  hospital,  where  I  attended  him 
a  few  hours  after  the  accident.  The  eye-lids  of  this  organ 
were  ecchymosed,  the  conjunctiva  red  and  swollen,  the  trans- 
parent cornea  divided,  at  its  lower  part  and  near  its  point  of 
adhesion  to  the  sclerotica,  by  a  fringed  cut,  through  which  a 
flap  of  the  iris  protruded.  The  ball  of  the  eye  had  sunk  or 
was  depressed,  and  from  the  opening  into  the  cornea,  notwith- 
standing the  staphyloma  produced  by  the  iris  and  the  membrane 
of  the  aqueous  humour,  there  issued  an  albuminous  sanguineo- 
lent  fluid;  the  bottom  of  the  remainder  of  this  eye  was  of  a 
deep  brown  colour.  The  patient  complained  of  violent  pain 
in  the  orbit,  over  the  whole  corresponding  side  of  the  head, 
and  especially  at  the  temple. 

I  first  freed  the  eye  from  the  tears  and  blood  with  which 
it  was  covered,  by  washing  it  freely  with  cold  water;  I  made 
numerous  scarifications  upon   the   ecchymosed  eye-lids,  and 


Diseases  of  the  Eye.  277 

finally  with  a  golden  style  returned  that  part  of  the  iris  which 
had  been  displaced  and  torn  from  a  portion  of  its  internal  ad- 
hesion (on  the  nasal  side).  This  reduction  being  accomplished 
with  every  possible  care,  and  the  edges  of  the  wound  being 
drawn  together  and  placed  in  contact,  and  having  washed  the 
eye-lids  with  Goulard  water,  1  closed  them  and  caused  them 
to  be  kept  so  by  one  of  my  assistants,  whilst  I  opened  with 
the  lancet  one  of  the  temporal  arteries  in  order  to  obtain  a  direct 
depletion.  The  small  orifice  made  in  this  way  was  reunited 
with  a  strip  of  adhesive  plaster,  and  in  conclusion  I  applied 
a  retaining  bandage  over  the  eye,  as  over  the  whole  temporal 
region  of  the  same  side.  The  patient  was  kept  in  the  dark; 
confined  to  a  rigid  diet  and  to  the  use  of  acidulated  mucilagi- 
nous drinks,  sweetened  with  sugar  and  kept  cold;  I  directed 
ice  to  the  head  and  sinapisms  to  the  feet.  Tiie  local  pains  and 
the  cephalalgia  decreased,  and  the  patient  enjoyed  for  several 
quarters  of  an  hour  a  most  comfortable  rest;  but,  some  febrile 
action  having  become  developed  during  the  evening,  another 
copious  venesection  from  the  arm  was  resorted  to,  and  the  use 
of  ice  and  cooling  drinks  continued. 

On  my  visiting  him  the  next  day,  nervous  symptoms  hav- 
ing manifested  themselves,  I  directed  several  scarified  cups  to 
be  applied  to  the  nape  of  the  neck  and  between  the  shoulders. 
The  other  treatment  was  continued,  the  dressings  were  not 
disturbed,  and  not  removed  entirely  until  the  ninth  da)'. 

We  were  fully  persuaded  that  this  eye  was  lost,  or  that  at 
least  it  would  remain  deprived  of  the  functions  of  vision,  which, 
in  fact,  had  already  occurred  at  the  time  of  the  accident;  but 
to  our  great  and  most  agreeable  surprise,  the  ball,  which  had  at 
first  been  depressed  or  reduced  to  a  very  small  volume,  owing 
to  the  loss  of  the  crystalline  lens,  and  doubtless  also  of  a  part 
of  the  vitreous  humour,  had  resumed,  or  very  nearly  so,  its 
original  form  and  natural  size.  The  patient  told  us  that  he 
had  had  a  glimpse  of  light;  yet,  there  was  still  a  very  great 
confusion  in  the  anterior  chamber,  and  the  aqueous  humour 
never  ceased  to  issue  through  the  wound  of  the  cornea,  where, 
"besides,  small  and  irregular  membranous  flaps  could  be  per- 
ceived, which  no  doubt  belonged  to  the  covering  of  this  liquor 


278  Diseases  of  the  Eye. 

and  which  we  cut  off  with  a  very  small  pair  of  curved  scissors. 
We  immediately  placed  the  eye-lids  again  in  contact;  I  put 
over  them  a  fine  compress,  moistened  previously  with  cam- 
phorated wine;  and  an  aromatic  poultice  was  laid  upon  the 
forehead  and  temporal  region  of  the  same  side,  taking  care 
not  to  let  it  come  too  near  the  affected  eye. 

The  application  of  ice  to  the  head,  the  use  of  mustard  pedi- 
luvia,  of  cooling  drinks  and  scarified  cups  frequently  repeated, 
were  persevered  in.  The  dressing  was  not  more  than  twice 
daily  renewed  for  the  purpose  of  changing  the  cataplasms:  after 
the  expiration  of  the  fifteenth  day,  however,  I  separated  the 
eye-lids  again  and  examined  carefully  what  had  taken  place  in 
the  interior  of  the  eye. 

We  perceived  in  the  first  place  the  pupil  indented  at  its  in- 
ferior segment,  with  a  considerable  inclination  towards  the 
temple;  contraction  had  been  preserved  at  this  external  half, 
while  the  other  half  which  corresponded  to  the  nose  had  lost 
it.  A  crescentic  flaw,  about  one  line  and  a  half  in  size  might 
be  observed  at  the  point  where  the  iris  adhered  to  the  in- 
ternal half  of  the  periphery  of  the  opening  of  the  sclerotica; 
which  flaw  appeared  to  us  to  be  owing  to  the  attachment  of 
the  iris  being  torn  off  at  that  point,  at  the  nasal  side  of  the 
opening  of  which  we  have  spoken  before.  In  other  respects 
the  patient  told  us  that  he  could  see  with  this  eye  the  light  a 
little  better,  and  he  thought  even  that  he  could  faintly  perceive 
large  objects  divided  into  two  unequal  portions,  but  in  a  man- 
ner still  very  much  confused.  From  that  moment,  we  left 
the  eye  free,  protected  merely  by  a  simple  piece  of  cloth,  and  all 
that  was  done  externally  was  to  bathe  it  daily  with  lotions 
composed  of  wine  slightly  camphorated  and  mixed  with  a 
strong  decoction  of  poppies. 

All  the  inflammatory  symptoms  dispersed  by  degrees,  and 
on  the  twentieth  day  the  wound  of  the  cornea  began  to  cica- 
trize, which  was  accomplished  towards  the  end  of  April. 
From  that  timethe  eye  assumed  a  round  appearance  and  seemed 
to  have  again  taken  its  shape,  and  very  nearly  also  its  original 
size.  The  opening  of  the  pupil  had  grown  smaller  and  inclined 
strongly  downwards  and  outwards  from  the  side  of  the  temple, 


Diseases  of  the  Eye.  279 

so  that  it  is  no  longer  enabled  to  receive  the  cone  of  the  lumi- 
nous rays  converged  by  the  transparent  cornea;  they  enter  almost 
entirely  through  the  lateral  and  crescentic  flaw  which  has  been 
mentioned.  However,  when  Pécheur  fixes  the  eye  in  its 
straight  line,  the  visual  cone  which  falls  upon  the  centre  of  the 
cornea,  simultaneously  penetrates  into  the  interior  through  the 
two  openings,  and  the  person  sees  then  every  object  double  or 
divided  in  two  parts,  but  they  are  still  clouded  and  surrounded 
by  a  variegated  light.  Armed  with  a  concave  lens  of  two 
degrees  and  looking  at  objects  in  sucli  a  way  as  to  see  them 
exclusively  through  the  internal  lateral  flaw,  he  will  be  able 
to  discern  them  exactly,  and  the  prismatic  colours  by  which 
they  are  surrounded  when  he  is  deprived  of  his  glasses,  are 
far  less  perceptible.  In  fine,  with  the  assistance  of  the  con- 
vex glass,  this  non-commissioned  ofiicer  can  see  any  objects 
simultaneously  with  the  right  eye,  and  thus  continue  to  pursue 
his  duties  and  functions.  He  left  the  hospital  on  May  15th, 
and  was  exhibited  before  the  philomathic  society  in  their  meet- 
ing of  the  29th  inst. 

1.  This  exceedingly  curious  fact  evidently  proves,  there- 
fore, that  the  vitreous  humour,  though  it  may  have  escaped  to 
a  considerable  amount  through  some  solution  of  continuity, 
can  and  actually  does  reproduce  itself.  The  first  proof  of  this 
we  met  with,  was  in  the  mounted  chasseur  of  the  ex-guard  of 
whom  we  have  given  an  account  above.  Being  dressed  upon 
the  same  plan  as  Pécheur,  the  eye  had  in  like  manner  resumed 
afterwards  its  original  shape  and  volume.  The  optic  functions 
were  even  more  perfectly  restored  in  that  case,  which  is  owing, 
however,  to  the  circumstance  that,  as  the  crystalline  lens  had 
not  left  its  receptacle  as  in  the  last  case,  there  was  consequently 
no  aberration  in  the  course  of  the  rays  of  light,  and  the 
chasseur  had,  therefore,  no  occasion  to  make  use  of  a  convex 
glass. 

2.  The  result  of  the  wound  of  Pécheur  appears  to  us  to 
have  been  analogous  to  that  which  occurred  in  an  individual, 
on  whom  the  operation  for  cataract  had  been  performed  by  an 
incision  made  at  the  base  of  the  transparent  cornea  and  by  an 
artificial  pupil  at  the  point  of  adhesion  of  the  iris,  near  the 


280  Diseases  of  the  Eye. 

nasal  side  of  the  opening  of  the  sclerotica,  where  it  attaches 
itself,  so  as  to  impart  to  this  laceration  a  crescentic  shape.  We 
have  reason  to  believe  tliat  vision  will  improve  still  more  in 
this  eye  and  that  the  perception  of  objects  will  become  still 
more  exact,  as  soon  as  nature  shall  have  accustomed  herself  to 
make  the  visual  cone  enter  altogether  through  this  lateral  flaw, 
which  has  besides  increased  in  size. 

Sixth  Observation.  Another  instance  of  those  remarkable 
optic  changes,  of  which,  as  far  as  I  know,  nobody  has  as  yet 
spoken,  presented  itself  recently  for  my  observation  in  the 
person  of  one  Anthony  Scarlati,  a  native  of  Turin  in  Savoy, 
and  a  serjeant  of  the  6th  regiment  of  infantry  of  the  royal 
guards.  This  soldier,  holding  then  the  same  rank  in  the 
twelfth  regiment  of  light  infantry,  during  the  siege  of  Sara- 
gossa,  in  1808,  had  been  struck  by  a  ball,  while  near  the  end 
of  its  course,  on  the  superior  and  external  lateral  margin  of  the 
right  orbit.  So  violent  a  contusion  instantaneously  resulted 
in  an  extensive  ecchymosis  spreading  over  the  affected  parts, 
and  in  the  loss  of  vision  on  the  same  side.  Inflammatory 
symptoms  having  come  on,  the  patient  had  been  compelled  to 
repair  to  the  ambulances,  where  he  passed  several  weeks 
without  being  able  to  see  out  of  this  eye,  in  order  to  undergo 
the  treatment  which  was  indicated  in  this  case,  and  which  con- 
sisted in  general  bleeding,  in  the  application  of  leeches  around 
the  eye-lids,  in  the  internal  exhibition  of  refrigerants,  and  in 
the  use  of  anodyne  collyria  externally. 

After  this  treatment,  and  ever  since  the  return  of  vision  to 
the  eye  which  had  been  contused, remarkable  changes,  which  we 
shallendeavour  to  explain,  manifested  themselves  forthwith  in 
the  functions  of  this  organ  and  continued  so  for  fifteen  years 
afterwards,  when  finally  this  non-commissioned  officer,  on  his 
arrival  in  Spain,  during  the  late  expedition  in  1S23,  experi- 
enced an  almost  total  loss  of  sight.  The  following  are  the 
results  of  an  examination  of  the  patient  which  we  recently  had 
an  opportunity  to  make.  1.  The  pupil  and  the  iris  are  in  a 
state  of  unnatural  contraction;  they  are  consequently  smaller 
than  those  of  the  left  eye,  and  have  receded  about  two  lines. 
2.  At  the  upper  portion  of  this  membrane  a  deviation  or  rent 


Diseases  of  the  Eye.  .  281 

inay  be  observed,  which  detaches  its  great  periphery  from  the 
corresponding  margin  of  the  sclerotica,  in  a  diameter  propor- 
tionate to  the  displacement  of  the  pupil.  The  latter  retains 
in  ils  lower  segment  some  little  power  of  motion,  of  which  it 
is  deprived  in  its  upper  half.  The  result  of  this  twofold  alte- 
ration is  that  the  person  sees  objects  double  or  divided  into  two 
unequal  parts,  and  that  under  certain  circumstances,  according 
to  the  direction  given  by  him  to  the  ball  of  the  eye  and  to  the 
eye-lids,  he  can  at  times  only  discern  separately  the  figures 
placed  in  the  situation  of  the  superior  fissure;  and  at  times 
only  those  which  are  in  a  line  with  the  pupil.  Thus,  for  in- 
stance, if  the  upper  eye-lid  has  been  separated  by  the  indivi- 
dual himself,  and  the  eye  looks  verticall}^  upwards,  he  will 
perceive  only  the  figures  which  are  above  him  through  this 
artificial  rent,  while  the  rays  of  those  figures  are  prevented 
from  passing  through  the  pupil.  Again,  if  the  eye-lid  is 
lowered,  and  the  person  looks  downwards,  the  pupil  alone 
and  exclusively  will  in  its  turn  receive  the  impression  of  the 
objects  which  are  to  be  seen  on  the  horizon.  At  last,  when 
the  eye  is  fixed  in  its  axis,  the  eye-lid  being  still  separated, 
the  rays  of  figures  penetrate  at  once  and  simultaneously 
through  the  two  openings  into  the  interior  of  the  globe  of  the 
eye,  which  in  the  person  establishes  a  sort  of  amblyopia.  To 
oculists  I  must  leave  the  merit  of  contriving  some  particular 
method  of  centring  the  rays  of  light  in  such  cases,  and  of  ren- 
dering the  perception  of  objects  in  their  unity  and  real  character 
more  convenient.  The  accidental  opening  which,  in  the 
instance  of  Scarlati,  exists  above  the  pupil,  and  which  certainly 
had  been  produced  only  by  the  destruction  of  the  natural  ad- 
hesions of  the  iris  to  the  superior  margin  of  the  foramen  of 
the  opaque  cornea,  proves  moreover  that  the  adhesions  uniting 
.these  two  membranes  are  very  slight  and  delicate. 

As  to  the  almost  total  extinction  of  sight  which  this  eye  ex- 
perienced during  the  late  expedition  to  Spain,  it  was  owing  no 
doubt  to  the  fact  that  the  crystalline  lens,  whose  nutritious 
vessels  had  been  violently  shaken  by  the  shot  in  the  orbit, 
had  gradually  lost  its  properties  and  become  opaque,  begin- 
ning at  its  superior  part  (the  spot  nearest  to  the  concussion), 
for  there  remains  yet  a  little  lucidity  at  its  inferior  half- 
2  L 


282  Diseases  of  the  Eye. 

Without  confining  my  attention  to  the  other  diseases  to 
which  the  ball  of  the  eye  is  particularly  exposed,  and  which 
have  already  been  sufficiently  described  by  authors,  I  shall  now 
develope  my  opinion  on  the  properties  of  the  iris,  and  on  the 
want  of  relation  existing  between  this  membrane  and  the 
immediate  organs  of  vision,  the  optic  nerve  and  the  retina. 

I  have  generally  observed  that  the  irritation  or  the  changes  to 
which  the  nervous  system  of  organic  life  is  liable,  exert  directly 
or  indirectly  an  influence,  more  or  less  decided,  upon  the  nerves 
of  relation,  while  the  injuries  which  are  exclusively  confined  to 
the  latter,  have  little  or  no  effect  upon  the  integrity  of  the 
functions  of  the  nerves  or  organs  of  internal  life,  or  these 
effects,  if  they  should  become  apparent,  are  infinitely  more 
tardy  than  in  the  former.  In  order  to  sustain  this  opinion,  I 
could  examine  by  comparison  the  influence  which  the  diseases 
of  one  of  these  nervous  systems  produce  upon  the  other,  and 
vice  versa.  This  is  an  undertaking  which  I  deem  highly  im- 
portant, and  which  might  form  the  subject  matter  of  an 
important  investigation  in  ph3'-siology  and  pathology;  but 
under  the  expectation  that  this  question  will  soon  be  agitated, 
I  propose  to  examine  what  is  the  nature  of  the  sympathetic 
relation  which  exists  between  the  iris  and  the  retina,  or  the 
optic  nerve. 

It  has  been  strictly  believed  to  this  day  that  the  iris  derived 
its  contractile  or  retractile  power  from  the  nervous  influence 
of  the  optic  nerve  or  the  retina:  a  majority,  therefore,  of  the 
advocates  of  this  doctrine  formerly  recommended  never  to 
operate  for  cataract,  especially  by  extraction,  when  the  iris 
was  deprived  of  its  motions,  for  they  presumed  that  in  this 
case  the  organ  of  vision  was  paralysed  likewise;  but  since 
then  experience  having  taught  that,  under  certain  circumstan- 
ces, the  optic  functions  are  resuscitated  after  the  depression  or 
extraction  of  the  cataract,  notwithstanding  the  immobility  of 
the  iris,  it  has  been  supposed  that  this  membranous  partition 
can  contract  only  so  far  as  the  retina  may  receive  the  im- 
pression which  it  requires  in  order  to  effect  the  contraction.* 

*  See  "  Dictionnaire  des  Sciences  Médicales,"  and  other  classical  authors  on 
the  diseases  of  the  eyes. 


/  Diseases  of  the  Eye.  283 

Far  from  it  that  the  iris  should  thus  depend  upon  the  ner- 
vous influence  of  the  retina  or  the  optic  nerve,  my  researches 
and  the  observations  which  I  have  collected,  have  convinced 
me  now,  that  the  properties  of  this  membrane  emanate  chiefly 
from  its  peculiar  texture  and  from  the  ciliary  nerves  which  it 
principally  receives  from  the  lenticular  ganglion  of  the  great 
sympathetic.  This  disposition  throws  some  light  on  the  na- 
ture of  its  paralytic  affection,  when  it  does  exist,  and  on  the 
reasons  why  the  same  affection  does  not  occur,  whenever  the 
optic  nerves  are  paralysed  or  altered  by  any  particular  disease. 
Thus  I  have  seen  cases  of  gutta  serena,  in  which  the  iris  had 
retained  its  motive  powers.  The  little  Englishman  whose 
sight  I  had  the  good  fortune  to  restore  in  Spain,  after  the 
battle  of  Corunna,  (see  the  article  Moxa,  Clinique  Chirurg. 
Vol.  III.)  furnishes  an  incontrovertible  proof  of  it. 

In  cases  of  well  formed  cataract,  the  retina  can  preserve  its 
integrity,  be  capable  again  to  resume  its  functions,  as  soon  as  it 
shall  be  enabled  to  receive  the  impression  of  objects  by  the 
extraction  or  depression  of  the  dusky  veil  by  which  the  pass- 
age of  the  rays  of  light  is  intercepted,  although  the  iris  should 
be  paralysed,  for  this  latter  affection  depends  upon  the  lesion 
of  a  set  of  nerves  which  belongs  to  the  internal  functions,  and 
which  communicates  only  indirectly  with  those  of  the  life  of 
relation,  by  means  of  delicate  nervous  anastomoses.  I  wish, 
however,  to  be  well  understood  that  from  this  rule  I  deduct 
the  adhesions  which  the  iris  may  form,  and  which  are  liable 
to  1)6  confounded  with  a  paralysis  of  this  membranous  par- 
tition. 

I  shall  now  proceed  to  relate  some  cases  with  reference  to 
the  vievirs  which  I  have  just  advanced  on  the  properties  of  the 
iris,  and  on  the  independence  of  the  affections  of  this  membrane, 
and  of  those  by  which  the  direct  organs  of  vision  may  become 
attacked. 

The  following;  case  will  concern  the  lesion  of  the  nerves 
which  endow  the  iris  with  motive  power.  The  subject  of  it 
is  M.  Charles  Ripault,  a  corporal  of  the  sixth  troop  of  lancers 
of  the  royal  guards,  27  years  old,  who  had  been  admitted  into 
the  hospital  on  May  19th  1827,  the  sixth  day  after  he  had  re- 


284  Diseases  of  the  Eye.  ^ 

ceived  a  wound  in  the  right  eye  from  a  thrust  svith  a  buttonless 
foil. 

This  wound  instantaneously  occasioned  a  paralysis  of  the 
iris,  as  was  indicated  by  the  extreme  dilatation  of  the  pupil, 
and  by  its  immobility.  Notwithstanding  this,  vision  was  pre- 
served so  as  to  enable  him  toappreciate  all  the  physical  quali- 
ties of  external  objects,  with- this  modification  only,  as  the 
patient  declares,  that  the  representations  of 'those  objects 
appeared  to  him  to  be  cloudy  towards  their  centre,  while  he 
could  discern  them  perfectly  around  the  circumference. 

The  seat  of  the  injury  was  the  internal  angle  of  the  eye 
outside  and  rather  below  the  caruncula  lachrymalis,  inasmuch 
as  the  point  of  tbe  instrument  had  penetrated  obliquely  as  far 
as  the  bottom  of  the  internal  wall  of  the  orbit,  and  had  injured 
the  corresponding  side*  of  the  sclerotica,  and  with  it  no  doubt 
also  the  branches  of  the  nasal  nerve  which,  at  that  very  point, 
pass  through  the  substance  of  this  membrane  in  their  way  to 
the  iris,  as  well  as  through  the  tendinous  attachments  of  the 
troehlearis  muscle.  The  patient  had  instantly  dropped  down 
and  fainted  away. 

The  inflammation  which  had  already  come  on,  when  admit- 
ted into  the  hospital,  had  been  subdued  by  bleeding  from  the 
,  temporal  artery,  by  scarified  cups  applied  to  the  nape  of  the 
neckj^  and  to  the  dorsal  regions,  by  mustard  pediluvia,  by  the 
application  of  ice  to  the  head,  and  by  refrigerants.  The 
paralysis  of  the  iris  remained;  but,  by  the  application  of  seve- 
ral small  moxas  to  the  temple,  and  by  means  of  convex  glasses 
for  the  injured  eye,  the  imperfection  of  sight  had  been  greatly 
relieved. 

A  gun-smith's  apprentice,  14  years  of  age,  received,  in  1S18, 
by  mistake,  a  blow  with  a  musket  ramrod  upon  the  central 
part  of  the  inferior  margin  of  the  left  orbit.  This  violent 
shock  was  followed  immediately  by  the  loss  of  vision  of  the 
eye  of  ^that  side,  while  the  iris  retained  the  power  of  motion 
unimpaired,.  He  continued  in  tliis  condition  for  ten  or  eleven 
months,  and  when  he  became  apprehensive  of  the  loss  of  the 
other  eye,  the  sight  of  which  seemed  to  him  to  grow  weaker, 
he  called  upon  me  for  advice.     After  a  careful  examination  of 


Diseuses  of  ih&  Eye.  -       285 

it,  I  pursued  the  following  mode  of  treatment  :  first  of  all  sca- 
rified cups  were  applied  to  thejeft  temple,  to  the  nape  of  neck, 
to  the  neck  and  to  the  shoulders.  After  giving  him  a  gentle 
emetic,  I  put  him  upon  the  use  of  bitters,  and  began  with  the 
application  of  the  nioxa.  The  first  I  put  upon  the  left  side  of 
the, nape  of  the  neck  in  order  to  come  as  near  as  possible  to  tlie 
origin  of  the  optic  nerves;  a  second  was  applied  between  the 
angle  of  the  left  maxilla  and  the  mastoid  process  upon  the  course 
of  the  trunk  of  the  facial  nerve  of  the  same  side;  and  four  or 
fi'^e  smaller  ones  were  put  in  succession  upon  the  corresponding 
temporal  region.  After  tfie  application  of  the  first  moxas 
the  patient  became  sensible  of  the  impression  of  light,  and 
soon  after  could  distinguish  objects.  This  faculty  progressively 
increased,  and  finally  became  as  perfect  as  that  of  the  right 
eye.  The  motions  of  the  iris  had  never  ceased  to  go  on  with 
as  much  regularity  as  in  its  healthy  state,  which  circumstance 
iaduced  me  to  make  it  the  principal  object  of  my  reflexions. 

For  several  months  this  young  man  believed  himself  to  be 
cured  entirely,  and  indeed,  he  saw  out  of  both  eyes  with  equal 
accuracy.  After  that  space  of  time  he  observed,  however, 
that  his  vision  on  the  left  side  sensibly  declined,  and  soon  after 
iie  was  deprived  of  it  altogether.  Being  alarmed  at  this  new 
occurrence,  he  again  requested  me  to  give  him  my  advice.  I 
perceived,  in  fact,  that  a  complete  cataract  had  intercepted  the 
passage  of  the  rays  of  light  into  this  eye,  and  produced  on  that 
side  total  blindness,  whilst,  at  the  same  time  the  iris  had  pre- 
served its  motive  faculty,  and  was  in  a  perfectly  sound  con- 
dition. There  are  then  tvvo  remarkable  phenomena:  the  first 
is  the  paralysis  of  the  retina  and  the  loss  of  the  visual  faculties, 
while  the  iris  itself  had  not  undergone  the  least  change  of 
structure;  the  second  sljowed  itself  in  the  sudden  forma- 
tion of  the  cataract.  The  one  furnishes  an  irresistible  proof 
of  the  properties  of  the  iris*  being  independent  of  the  retina; 

*The  effects  of  belladonna,  the  application  of  which  to  the  conjunctiva,  or 
even  to  the  eye-lids,  paralyses  the  iris  instantaneously,  without  depriving  the  Indi- 
vidual of  the  power  of  sight,  aflTord  another  proof  that  the  vital  properties  of  this 
membrane  are  dependent  upon  the  branches  of  the  oplithalmic  which  supply  the 
conjuncliva  and  the  eye-lids,  and  which  directly  communicate  with  the  ciliary 
uerves. 


286  Diseases  of  the  Eye. 

the  other,  that  the  crystalline  lens  does  not  derive  its  suste- 
nance by  inhalation,  as  has  been  conjectured  by  the  nriajority 
of  writers,  but  rather  by  a  species  of  vascular  circulation,  like 
all  the  other  living  parts  of  organized  bodies;  for  if  the  very 
slender  vessels  of  the  crystalline  lens  had  not  been  ruptured 
in  their  passage  from  the  capsular  membrane  to  the  lens,  it 
would  never  have  lost  its  transparency  in  so  sudden  a  manner.! 

This  last  assertion  is  the  more  authenticated,  as  in  the  case 
of  the  same  person,  whom  we  have  repeatedly  had  occasion  to 
see,  a  year  after  the  formation  of  his  cataract  (for  which  we 
applied  then,  nothing  else  but  an^emunctory  to  both  sides  of 
the  nucha  which  he  had  kept  open  during  that  time),  we  per- 
ceived to  our  great  astonishment  that  the  opacity  of  the  crys- 
talline lens  had  entirely  disappeared,  but  that  the  cataract 
nevertheless  had  been  reproduced  at  the  end  of  several  months. 
We  believe,  however,  still  that  this  relapse  must  be  owing  to 
the  suppression  of  the  discharge.  We  have  lost  sight  of  this 
patient,  and  have  therefore  not  been  able  to  follow  the  course 
of  his  disorder. 

A  not  less  remarkable  instance,  which  also  seems  to  prove 
that  the  crystalline  lens  participates  in  the  general  circulation, 
presented  itself  at  the  hospital  of  the  guards  in  the  person  of 
James  Bache,  a  private  of  the  second  Swiss  regiment.  This 
man,  in  consequence  of  a  violent  contusion  which  he  had 
received  upon  the  temporal  side  of  the  right  eye,  had  been 
attacked  with  a  cataract,  whose  commencement,  progress  and 
stationary  condition,  in  which  it  afterwards  remained  for  a 
pretty  long  time,  had  exhibited  features  quite  peculiar.  The 
disease  first  commenced  around  the  whole  circumference  of 
the  crystalline  lens,  the  centre  of  which,  remaining  perfectly 
lucid,  allowed  the  patient  to  distinguish  objects  quite  clearly, 
though  in  somewhat  smaller  proportions.  The  opacity  after- 
wards progressed  very  slowly  from  the  opaque  circumference 
of  this  body  towards  its  transparent  portion,  not  indeed  by  a 
circular  and  throughout   uniform   layer,   but  by   concentric 

t  Soemmering  has  injected  these  vessels  as  far  as  the  crystalline  capsule;  but 
as  they  do  not  admit  the  colouring  part  of  the  blood  beyond  this  covering,  it  has 
been  very  unadvisedly  thought  that  the  crystalline  lens  is  sustained  by  inhalation. 


Diseases  of  the  Eye.  287 

lines  or  rays,  in  the  spaces  of  which  there  existed,  of  course, 
other  divergent  rays,  partaking  of  the  same  degree  of  lucidity 
as  the  centre,  so  that  this  arrangement  imparted  to  the  peri- 
phery of  the  lens,  the  aspect  of  a  small  strip  of  cloth  irregularly 
divided.  Under  these  circumstances  it  appeared  to  the  patient 
as  if  all  external  objects,  wei'e  unequally  divided  also,  in  their 
largest  diameter;  and  it  is  sufficiently  easy  to  account  for  this 
optical  illusion,  which  doubtless  recognised  no  other  cause  than 
that  the  rays  of  light  were  infracted  and  interrupted  by  the 
opaque  lines  of  which  we  have  spoken.  In  the  course  of  time 
and  in  proportion  as  the  opacity  became  more  distinct  and 
began  to  spread  over  the  centre  as  well  as  between  these  lines, 
the  optic  effects  which  the  patient  experienced,  remaining 
upon  the  whole  the  same,  seemed,  besides,  to  be  increased  by 
a  slight  degree  of  cloudiness  the  obscurity  of  which  might 
have  been  interrupted  at  intervals.  Topical  revulsives,  so 
generally  resorted  to  under  such  circumstances,  produced  no 
other  effect  than  a  trifling  enlargement  of  the  lucid  portion  of 
the  crystalline  lens. 

A  young  lady  from  Paris,  seventeen  or  eighteen  years  of 
age,  has  furnished  us  with  a  third  specimen  of  a  case  perfectly 
analogous  to  the  last  mentioned.  Previously  to  undertaking 
her  cure,  she  had  been  introduced  to  our  esteemed  colleague 
M.  Demours,  honorary  member  of  the  Royal  Academy  of  Me- 
dicine. In  this  case  the  crystalline  lens  presented  a  white 
opaque  star  which  occupied  nearly  its  whole  anterior  surface; 
a  delicate  crown,  scolloped  in  its  lucid  circumference,  could 
be  with  difficulty  perceived,  and  through  it  this  young  person 
saw  the  light  and  the  truncated  shadows  of  the  objects  placed 
between  the  rays  of  the  sun  and  her  own  eye.  This  blindness 
had  by  degrees  arisen  from  the  opacity  of  the  centre  of  the 
crystalline  lens  and  appeared  daily  to  increase. 

After  having  unloaded  the  vessels  of  the  head  by  revulsive 
depletions,  such  as  scarified  cups  put  on  the  temple  and  nape 
of  neck,  we  applied  the  nioxa  to  the  first  mentioned  place  and 
to  the  corresponding  side  of  the  base  of  the  cranium:  the  num- 
ber, thus  applied  in  succession,  amounted  to  twelve.  Under 
the  influence  of  these  topical  revulsives  the  opacity  gradually 


288  Diseases  of  the  Eye. 

decreased,  and  four  months  later  the  young  lady  could  discern 
any  object  with  almost  as  much  distinctness  as  with  the  right 
eye.  Indeed,  at  that  time,  there  could  be  nothing  more  per- 
ceived on  the  ocular  lens  buta  trifling  cloudiness  of  a  whitish 
aspect,  of  the  size  of  a  very  small  lentil,  which  in  the  course  of 
time  will  also  finally  disappear.  Since  she  had  gone  into  the 
country  without  my  knowledge,  I  could  not,  to  my  great  regret, 
present  h^  again  to  M.  Demours. 

Without  this  vascular  circulation  which  necessarily  exists 
between  the  crystalline  capsule  and  its  lens,  it  would  certainly 
be  difficult  to  explain  the  causes  of  the  return  of  lucidity  to' 
this  transparent  body,  after  it  has  once  become  opaque. 

In  the  instance  of  tetanus,  where  all  the  muscles,  excited  by 
the  nerves  of  organic  life,  are  in  a  state  of  permanent  retraction 
or  contraction,  the  properties  of  tl^e  iris  never  sustain  any 
change,  and  the  alternating  contraction  and  dilatation  of  the 
pupil  may  be  observed  to  go  on  as  in  the  healthy  state. 
.  In  certain  diseases  of  the  brain,  as  dropsical  effusion  into  the 
ventricles,  the  same  phenomena  will  be  observed.  The  sen- 
sitive functions  are  considerably  weakened  or  paralysed  by 
the  concentric  or  excentric  pressure  which  the  nerves  of  the 
sentient  organs  (as  those  of  vision  for  example)  have  to  endure 
at  their  origin,  in  consequence  of  the  dilatation  of  the  ventri- 
cles; while  the  iris  remains  unimpaired  and  retains  its  motive 
powers,  which  even  may  be  sympathetically  augmented  by  the 
irritation  induced  in  the  system  of  the  organs  of  internal  life 
by  means  of  drastic  or  emetic  medicines.*  An  English  lady 
wlTo  had  been  afiiicted  with  this  disease,  two  children  whom 
I  have  attended  also  in  Paris,  and  a  mounted  grenadier  of  the 
guards,  while  under  my  care  at  the  hospital  of  Gros  Caillou, 
have  furnished  me  with  striking  proofs  of  it.  There  is  no 
doubt  on  my  mind  that  in  this  grenadier,  after  a  violent  fall 
which  he  had  had  on  the  occiput,  effusion  had  taken  place  in 
the  ventricles  of  the  brain;  at  least,  he  displayed  all  the  usual 
symptoms;  dull  pain  accompanied  with  a  sense  of  weight  in 


•  In  verminous  disorders  (he  motions  of  the  iris  and  pupil  are  accelerated;  the 
pupil  may  likewise  be  made  to  contract  by  the  application  of  nitrate  of  silver  to 
the  conjyuctiva,  and  yet  vision  will  not  be  affected  thereby. 


Diseases  of  the  Eye.  289 

the  head,  a  remarkable  decline  of  all  the  senses  and  of  the 
faculty  of  speech,  a  sensible  change  in  the  powers  of  locomo- 
tion, paralysis  in  the  second  degree  of  the  arm  of  the  right 
side,  numbness  and  habitual  coldness  of  the  legs.  The  intel- 
lectual faculties  alone  remained  in  their  natural  condition. 
Nevertheless,  the  iris  of  this  man,  whom  by  the  application  of 
moxas  I  restored  to  health,  retained  all  its  properties  and 
motions.  I  observed  even  that  the  pupil  contracted  in  pro- 
portion as  drastic  purgatives  were  more  or  less  briskly 
administered.  The  same  fact  I  have  had  occasion  to  notice  in 
a  great  many  individuals  who  had  met  with  injuries  of  the  head, 
attended  with  loss  of  siglit  and  a  sensible  change  in  all  the  or- 
gans of  the  life  of  relation. 

The  iris  for  the  same  reason  may  lose  its  organic  properties, 
whilst  the  optic  nerve,  the  retina  and  the  other  parts  of  the 
eye  may  preserve  their  utmost  integrity  and  perform  all  their 
functions.  A  female,  thirty-four  years  old,  of  brown  com- 
plexion and  of  a  robust  and  healthy  constitution,  presented  a 
disorder  of  the  same  nature;  in  both  her  eyes  the  iris  had  been 
completely  paralysed,  and  was  dilated  in  three-quarters  of  its 
diameter;  by  the  application  of  the  most  powerful  stimulants 
and  by  the  sudden  impression  of  a  glaring  light  the  aperture 
of  the  pupil  could  with  difficulty  be  made  to  contract  for  about 
a  quarter  of  a  line.  Notwithstanding  this  very  perceptible 
deformity,  she  could  observe  objects  very  well,  and  could  even 
accurately  distinguish  their  forms  and  colours,  provided  they 
were  not  too  near  her  eyes. 

In  several  soldiers'of  the  guards  I  have  had  occasion  also  to 
observe  this  membrane  to  lose  its  motive  powers  completely, 
owing  to  a  concussion  received  upon  the  margin  of  the  orbit, 
or  after  an  injury  of  the  cornea  with  a  sharp-pointed  instru- 
ment, accompanied  with  lesion  of  the  gi-eater  periphery  of  the 
iris,  while  the  faculty  of  vision  itself  remained  imimpaired; 
but,  on  the  other  hand,  it  is  equally  true  to  state  that  the  same 
mechanical  causes  are  capable  of  destroying  the  vital  proper- 
ties of  one  or  the  other  membrane,  as  we  have  ourselves  more 
especially  observed  in  a  life-guardsman  and  in  a  soldier  of  the 
2  M 


290  Diseases  of  the  Eye. 

royal  guards:  the  latter  was  even  on  that  account  discharged 
from  the  service. 

In  cases  of  organic  affections  of  the  internal  viscera,  such  as 
the  chronic  phlegmasise  of  some  of  the  principal  viscera  of  the 
abdomen,  the  opening  of  the  iris  becomes  dilated  by  degrees, 
ivhile  the  retina  preserves  the  integrity  of  its  optic  functions. 

My  remarks  on  iritis,  or  inflammation  of  the  iris,  show  that 
this  inflammation,  which  most  commonly  may  be  traced  to 
repelled  syphilis,  after  having  passed  through  all  its  stages,  is 
attended  by  the  following  results,  as  the  Austrian  Professor 
Beer  has  judiciously  pbserved:  1.  By  discoloration  of  the  an- 
terior surface  of  the  diseased  membrane;  2.  By  the  fraying  or 
destruction  of  a  part  of  the  diameter  of  its  pupillary  opening, 
and  more  especially  of  its  superior  segment.  I  have  never 
observed  that  the  notch  which  is  apt  to  form  in  the  superior 
part  of  this  membrane,  had  occurred  alike  in  its  inferior  part: 
the  latter  loses  its  motive  power,  whilst  the  flap  which  sur- 
vives the  destruction  of  the  other,  retains  it  more  or  less 
perceptibly.  I  have  repeatedly  witnessed  this  phenomenon; 
but  it  never  appeared  to  me  so  conclusive  as  in  the  case  of  a 
mounted  grenadier,  who  had  been  attended  in  my  wards, 
where  it  seemed  to  depend  on  the  distribution  of  the  nerves 
and  of  the  ciliary  vessels  which  run  chiefly  from  above  over 
the  whole  remainder  of  this  membrane. 

An  officer  of  the  British  navy,  twenty-seven  or  twenty- 
eight  3^ars  of  age,  had  been  suddenly  attacked  by  a  violent 
ophthalmia,  accompanied  with  iritis.  There  were  some  slight 
ulcerations  upon  the  transparent  cornea  and  a  prodigious  swell- 
ing in  the  ocular  conjunctiva,  which  being  the  result  of  a 
metastasis  of  the  repelled  syphilitic  virus  of  one  or  more 
chancres  on  the  penis,  had  produced  a  genuine  chemosis. 
This  serious  disorder,  which  luckily  had  been  treated  and 
subdued  by  the  proper  remedies,  was  succeeded  by  discolora- 
tion and  paralysis  of  the  iris,  the  pupil  of  which  remained 
dilated,  whilst  the  optic  functions  were  preserved.  The 
chemosis  had  been  dissected  out  throughout  the  whole  peri- 
phery of  the  transparent  cornea;  but  there  are  still  a  pretty 
considerable  number  of  red  capillary  vessels  which  run  across 


I 


Diseases  nf  the  Eye.  291 

lire  cornea  from  one  side  to  the  other,  and  which  must  be  de- 
stroyed in  order  to  restore  it  to  its  entire  lucidity. 

The  preceding  remarks  and  cases  will,  we  trust,  sufficiently 
prove  that  the  retina  and  the  iris  may  be  affected  simulta- 
neously or  separately,  according  to  the  nature  or  the  modus 
operandi  of  the  causes  productive  of  the  change  of  structure; 
but  amongst  these  causes  there  is  one  as  remarkable  as  it  is 
rare,  which  we  may  further  adduce  in  support  of  our  views; 
this  is  the  direct  impression  which,  under  certain  circumstan- 
ces, the  rays  of  the  sun  are  apt  to  produce  upon  the  texture 
of  these  membranes.  Numerous  persons  had  become  subject 
to  the  influence  of  this  cause  on  the  day  of  the  eclipse  of  that 
constellation,  the  7lh  September  1820. 

From  amongst  the  cases  which  I  had  collected  on  this  occa- 
sion, I  propose  to  select  only  the  two  following,  as  they  were 
accompanied  by  some  peculiar  circumstances,  and  by  pretty 
serious  occurrences. 

The  subject  of  the  first,  of  the  name  of  J.  B.  Jacquemart,  a 
corporal  of  thé  artillery  train,  being  inexperienced  in  the  man- 
ner of  observing  a  solar  eclipse,  had  made  use  of  a  darkened 
piece  of  glass  with  a  clear  spot  in  its  middle,  which  he  had 
himself  made  there,  on  purpose  of  being  thereby  better  ena- 
bled to  observe  that  celestial  phenomenon.  Notwithstanding 
the  smart,  troublesome  and  very  painful  impression  which  the 
passage  of  the  sun's  rays  had  made  upon  him  through  the  trans- 
parent part  of  the  glass,  he  yet  continued  to  look  at  it  until  the 
end  of  the  eclipse;  when,  soon  afterwards,  he  was  seized  with 
vertigo,  a  lively  pain  along  the  whole  right  side  of  the  head, 
corresponding  with  that  of  the  eye,  through  which  he  had  ob- 
served it,  and  was  almost  deprived  of  vision  in  that  eye;  the 
iris  and  the  other  parts  of  this  organ  remained  unhurt.  Some 
weeks  after,  this  soldier,  suffering  continually  from  acute  pain 
in  his  head,  repaired  to  the  hospital,  where  I  attended  him. 
The  vessels  of  the  affected  eye  were  injected,  and  the  pupil  a 
little  more  contracted  than  that  of  the  left  side;  it  had,  how- 
ever, retained  its  power  of  motion,  although  the  vision  was 
much  obscured  and  almost  annihilated. 

In  this  instance,  then,  it  will  be  seen  that  a  very  small  cone 


292  Diseases  of  the  Eye. 

of  solar  rays  had  directly  reached  the  retina,  and  that  its  irri- 
tating effect  had  communicated  itself  to  the  optic  nerve,  as  far 
even  as  its  origin  in  the  interior  of  the  brain.  After  two 
blood-lettings  from  the  temporal  artery  and  jugular  vein,  I  ap- 
plied cups  to  the  temple  and  nape  of  the  neck;  and  afterwards 
had  recourse  to  the  employment  of  ice  upon  the  head  and  of  sev- 
eral moxas,  which  completely  restored  the  function  of  vision. 
Nevertheless  the  patient  ever  afterwards  felt  a  dull  pain  in  the 
whole  right  side  of  his  head. 

The  subject  of  the  second  case,  J.  B.  Paintiaux,  a  private  of 
the  5th  regiment  of  infantry  of  the  guards,  entered  the  hospital 
about  the  time  when  the  former  left  it.  He  had  used  his  left 
eye  for  observing  the  eclipse  of  the  sun,  with  the  assistance  of 
a  glass,  the  centre  of  which  was  opaque,  and  its  periphery  lucid 
or  transparent.  He  had  been  less  incommoded  than  the  other, 
because  the  sun's  rays  had  not  been  directed  against  the  pupil, 
through  which  they  had  passed  only  much  broken,  while  the 
circumference  of  the  transparent  cornea,  and  especially  the 
ocular  conjunctiva,  most  forcibly  received  the  impression  of 
these  rays,  which  set  such  an  intense  idiopathic  inflammation 
on  foot,  that  the  blood-vessels  of  this  membrane  had  become 
injected  as  far  as  the  centre  of  the  cornea,  through  a  slight 
albugo  which  had  simultaneously  formed  itself  over  a  large 
proportion  of  its  surface.  The  employment  of  antiphlogistic 
remedies  diminished  these  symptoms;  but  the  pupil  is  consid- 
erably reduced,  and  the  iris  has  lost  its  motive  power,  while 
the  retina  has  retained  its  optic  properties. 

If  the  affections  of  vision  which  result  from  this  cause  are  of 
rare  occurrence,  those  which  proceed  from  an  electric  shock, 
as  from  a  flash  of  lightning  for  instance,  must  be  not  less  so, 
for  it  is  pretty  difficult  to  understand  how  the  electric  spark 
could  precisely  change  that  part  of  the  brain  which  gives  ori- 
gin to  the  optic  nerves,  or  the  parts  of  the  eye  which  enter  into 
the  composition  of  sight,  without  leaving  some  external  marks 
behind,  or  without  attacking  in  some  measure  the  remainder 
of  the  encephalon  or  the  organs  of  the  other  senses.  The  fact 
which  we  are  going  to  relate  furnishes,  however,  an  instance 


Disensea  of  the  Eye.  293 

of  such  a  cause,  which  by  some  means  or  other  hnd  separately 
operated  upon  the  orgnns  of  vision. 

During  the  fall  of  1S19,  Pclcr  Kouvray,  whilst  watchinjr  a 
flock  of  sheep,  and  believing  it  to  be  on  the  eve  of  a  violent 
tempest,  took  refuge  under  a  tree,  against  the  trunk  of  which 
he  leaned,  when  he  received  about  his  head  an  electric  shock 
(a  stroke  of  thunder  as  the  patient  expressed  himself)  at  the 
moment  of  the  passage  of  the  lightning  through  this  tree,  sev- 
eral of  the  principal  branches  of  which  had  been  severed  from 
it.  The  shock  experienced  by  Rouvray  had  been  such,  that 
he  became  instantaneously  deprived  of  vision,  staggered,  and 
was  compelled  to  sit  down,  that  he  might  not  lose  his  balance. 
From  that  time  he  never  ceased  to  see  objects  in  a  turbid  light, 
and  to  feel  almost  habitually  some  kind  of  trembling  sensation 
in  both  globes  of  his  eyes.  Nevertheless,  when  at  the  re- 
cruiting season  he  had  drawn  the  lot,  he  was  transfc-red  as 
fusilcer  to  the  second  regiment  of  the  guards,  where  soon  after- 
wards he  was  attacked  with  a  nervous  fever  which  consider- 
ably aggravated  his  original  affection.  At  the  time  when  he 
entered  the  hospital,  which  happened  some  time  in  the  month 
of  October  1824,  this  man  could  scarcely  discern  the  colours 
or  the  forms  of  objects  by  the  light  of  day,  whilst  he  was  capa- 
ble of  distinguishing  perfectly  well  all  their  physical  proper- 
ties in  the  utmost  darkness  of  night;  but  at  the  same  time, 
and  whilst  his  eye-lids  were  closed,  he  was  troubled  with  hal- 
lucinations more  or  less  varied.  At  times  he  perceived  flashes 
of  fire  interspersed  with  all  colours;  at  others,  objects  multi- 
plied and  of  different  shapes  and  forms,  which  disturbed  his 
slumbers  and  kept  him  almost  continually  in  a  state  of  in- 
somnia. To  these  aberrations  were  superadded  a  ])ainful  feel- 
ing of  pressure  about  the  head,  nervous  spasms  in  all  the  limbs, 
an  almost  complete  dilatation  of  both  pqpils,  and  the  habitually 
rotatory  motion  of  the  globe  of  the  eyes,  which  has  been  men- 
tioned before.  The  pulse  was  tremulous,  small  and  febrile, 
the  skin  almost  imperspirable,  and  the  emaciation  of  body  ex- 
treme; the  digestive  functions,  however,  continued  to  be  car- 
ried on  sufliciently  well. 

After  having  taken  a  little  blood  from  him  by  means  of  cups, 


294  Diseases  of  the  Eye. 

applied  to  the  temples,  to  the  nape  of  the  neck  and  between 
the  shoulders,  and  after  having  acted  upon  the  stomach 
through  the  exhibition  of  a  mild  and  gentle  emetic,  we  re- 
sorted to  the  application  of  several  moxas  around  the  base  of 
the  cranium,  behind  the  ears,  and  to  the  temples.  After  the 
application  of  the  two  first,  which  had  been  put  between  the 
inferior  occipital  protuberances  and  the  mastoid  processes,  the 
trembling  of  the  globe  of  the  eyes  subsided;  the  pupils  imme- 
diately contracted  again;  the  hallucinations  considerably  abated, 
and  the  patient  could  bear  the  light  of  day.  Successive  appli- 
cations of  the  same  topical  revulsive  extended  this  improve- 
ment still  further  and  encouraged  us  to  anticipate  a  complete 
recovery.  He  had  already  begun  to  recover  his  strength; 
nutrition  went  on  more  perfectly,  and  sleep  had  again  become 
regular,  and  the  only  remaining  inconvenience  was  that  the 
patient  still  perceived  objects  in  the  dark  much  better  than 
through  the  medium  of  the  broad  light  of  day. 

Tonics  internally  administered,  weak  infusions  of  cinchona, 
a  generous  diet,  and  embrocations  with  phosphorated  spirituous 
lotions,  applied  externally  to  the  eyes,  have  principally  con- 
tributed to  the  condition  into  which  we  have  brought  him. 

An  analogous,  though  much  more  serious  occurrence,  which 
ouo'ht  to  be  ascribed  to  the  effects  of  laborious  microscopic  in- 
vestigations, presents  itself  at  the  present  day  in  the  person  of 
M.  de  Savigny,  a  member  of  the  Institute,  one  of  our  illustri- 
ous friends  and  associates  in  Egypt. 

It  is  no  doubt  exceedingly  difficult  to  point  out  the  causes 
of  the  motions  of  dilatation  and  contraction  of  the  pupil,  and 
to  explain  their  mechanism;  but  as  in  man  and  in  the  majority 
of  the  lower  animals  also  these  motions  appear  to  be  indepen- 
dent of  the  will  of  the  individual,  one  might  be  induced  to 
believe  that  the  stimulus  causing  the  contraction  of  the  fibres 
of  the  iris,  is  exclusively  furnished  by  the  nervous  twigs 
which  proceed  from  the  ophthalmic  ganglion,  and  which  belong 
to  the  nervous  system  of  organic  life.  But  then  it  should  be 
considered,  1,  that  this  membranous  curtain,  in  man  as  well  as 
in  several  animals,  receives  directly  one  or  two  filaments  from 
the  nasal  nerve  which  belongs  to  the  first  branch  of  the  fifth 


Diseases  of  the  Eye.  2.95 

pair  of  the  brain;  2,  that  the  motions  of  this  partition  seem  to 
be  subject  to  various  modifications  more  or  less  distinctly 
marked  in  the  same  individuals,  in  obedience  either  to  the 
influence  of  a  very  powerful  impression  of  light  irritating  this 
membranous  veil,  or  in  consequence  of  the  sudden  appearance 
of  images  of  a  more  or  less  exciting  aspect,  according  to  their 
colour  or  their  form;  3,  that  this  partition  seems  indeed  to 
perform  its  motions  under  the  influence  of  a  volition  which 
though  rarely  expressed  in  man,  is  yet  quite  perceptible  in 
certain  birds,  as  those,  for  example,  of  the  family  of  parrots.* 
After  these  observations  it  will  be  admitted  that  the  iris  is  an 
organ  of  a  mixed  character,  one  part  of  which  may  to  a  certain 
extent  and  in  certain  degrees  obey  the  dictates  of  the  will  of 
the  individual,  whilst  the  other  performs  its  functions  without 
the  latter  participating  in  it.t 

We  may,  therefore,  conclude  of  this  structure  (which  at  a 
later  period  I  intend  to  describe  more  in  detail),  and  of  the 
plan  of  distribution  of  the  nerves  which  supply  this  membranous 
curtain,  that  the  relaxation  of  the  iris  or  the  dilatation  of  the 
pupil  is  effected  by  the  puckering  up  of  the  flexuous  arteries 
which  are  freely  disposed  of  in  zigzag  or  in  spiroid  lines,  as 
well  as  by  the  engorgement  of  these  vessels,  occasioned  by  the 
stimulus  which  the  nervous  filaments  of  the  ophthalmic  gan- 
glion transmit  to  this  membrane,  while  the  contraction  of  this 
movable  curtain,  or  the  constriction  of  the  pupil,  is  doubtless 
effected  only  by  the  engorgement  of  the  small  arterial  or 
ciliary  crown,  after  the  manner  of  the  strings  of  a  purse. 
This  engorgement  would  seem  to  be  induced  by  the  stimulus 

*  According  to  (he  celebrated  Cuvier,  the  star-fish  not  only  appears  to  possess 
the  faculty  of  moving  the  pupil  at  will  like  the  parrots,  but  it  exhibits  besides  a 
prolongation  situated  at  the  superior  margin  of  this  opening,  and  arranged  in  the 
shape  of  a  closed  palm-leaf,  which  this  fish  doubtless  loweis  at  pleasure  before 
the  crystalline  lens,  after  the  fashion  of  a  blind.  In  the  torpedo  this  opaque 
membrane  is  complete,  whereby  he  is  enabled  to  close  the  pupil  entirely  at  will. 
(See  Leçons  iVAnalomie  Cuinparce,  Vol.  II.) 

■f  The  same  properties  may  be  observed  in  the  urinary  bladder,  the  sphincter 
of  which  contracts  in  obcdie-ice  to  the  stimulus  of  the  nerves  of  animal  life; 
while  the  body  of  tiiis  membranous  bag  receives  its  stimulus  from  those  of  or- 
ganic life. 


296  Diseases  of  the  Eye. 

of  the  long  ciliary  nerves  which  the  nasal  nerve  sends  off  to 
supply  the  circumference  of  this  opening,  without  communi- 
cating with  those  of  the  lenticular  ganglion;  in  this  way  the 
irritation  of  the  stomach  or  lungs  frequently  occasions  the  con- 
striction of  the  pupil,  while  those  of  the  intestines,  of  the 
uterus  or  bladder,  have  appeared  to  us  to  be  the  cause  of  its 
dilatation,  as  this  may  be  observed  occasionally 'in  infants 
troubled  with  worms. 

JSotwithstanding  these  two  nervous  systems,  the  motions  of 
the  iris  are  certainly  independent  of  the  nervous  influence  of 
the  retina,  of  which  assertion  the  account  of  the  following  facts 
will  furnish  completely  satisfactory  proofs: 

The  chamelion  has  no  movable  iris  in  the  interior  of  the 
eye;  the  functions  of  this  membrane  are  performed  by  the  ex- 
ternal eye-lid,  which  display  a  form  and  structure  quite 
peculiar.  Behind  the  transparent  cornea,  however,  and 
around  the  crystalline  lens,  may  be  seen  a  small  zone  of  a 
pearly  appearance,  interspersed  with  light  yellow  streaks  so 
fine  as  scarcely  to  be  perceived.  This  zone,  which  is  of  an 
extremely  close  and  compact  texture,  is  blended  with  the 
ciliary  processes,  and  adheres  to  the  periphery  of  the  crystalline 
lens,  the  anterior  segment  of  which  advances  beyond  its  edges 
by  about  a  line,  in  such  a  way  that  it  seems  to  have  no  other 
use  than  that  of  refracting  the  rays  of  light  towards  the  crys- 
talline lens,  while  the  external  orbitar  eye-lid  which  is  attached 
to  the  periphery  of  the  globe  of  the  eye  (whose  motions  it 
attends)  by  a  close  and  very  fine  membranous  fold  of  the  con- 
junctiva, dilates  or  contracts  its  opening  in  order  to  modify 
the  passage  of  the  rays  of  light,  by  means  of  two  plans  of 
circular  and  radiated  motor  fibres  which  enter  into  its  compo- 
sition. This  opening,  which  in  reality  supplies  the  place  of 
the  pupil,  has  a  round,  rather  elliptic  shape,  which  shuts 
entirely,  the  assertion  of  some  natural  philosophers  to  the  con- 
trary notwithstanding.  Another  singular  phenomenon  which 
may  be  observed  in  this  reptile,  is  that  he  moves  each  of  his 
two  eyes  invertedly,  and  seems  to  perceive  objects  in  opposite 
directions;  in  fact,  if  a  chamelion  and  a  tree-frog  {I'cina pra- 
tensis)  are  put  together  into  a  glass  vessel,  the  latter,  frightened 


Diseases  of  the  Eye.  297 

by  his  imminent  danger,  runs  about  the  cage,  anxious  to  avoid 
his  enemy;  the  chamelion,  without  stirring  in  the  least  from 
his  place,  pursues  his  prey  with  one  of  his  eyes,  while  the 
other  remains  fixed;  and  when  the  little  creature  least  expects 
it,  the  chamelion  seizes  him  with  liis  long  and  flexible  tongue 
and  swallows  him  with  the  utmost  composure. 

In  making  the  dissection  of  a  chamelion,  during  my  sojourn 
in  Egypt,  I  have  not  found  the  slightest  vestige  of  what  miglit 
be  regarded  in  him  as  the  organ  of  hearing,  of  which  he  seems 
to  be  destitute.  It  is,  therefore,  no  doubt  on  this  account 
that  nature  endowed  him  with  the  faculty  of  perceiving  with 
both  his  eyes,  simultaneously,  the  outlines  of  objects  which  are 
situated  in  opposite  directions. 

Prochaska,  one  of  the  most  able  anatomists  of  Europe,  by 
completely  successful  injections  which  are  in  my  possession, 
and  which  he  had  presented  to  me,  has  demonstrated  that  the 
structure  of  the  radiating  and  circular  vessels  of  the  iris  is  the 
same  as  that  of  the  elemenjary  fibre  of  the  muscles  or  of  the 
powers  of  locomotion.  These  injections  prove  that  the  fibres 
as  well  as  the  folds  and  circles  of  the  iris,  exactly  like  the 
spiral-like  fibres  of  the  arteries  themselves,  are  composed  of  a 
series  of  small  capillary  arteries,  very  perceptible  by  the  mi- 
croscope, which  are  entirely  or  partially  twisted  around  each 
other,  according  to  the  formation  or  particular  habits  of  each  of 
these  organs.  These  spiral-like  capillary  arterioles  are  sur- 
rounded and  interlaced  by  some  foreign  substance  which  is 
lost  in  the  injection,  and  the  same  anatomist  maintains  that 
it  partakes  of  the  nature  of  muscular  fibrin,  of  albumen  con- 
crete and  thickened  in  the  arteries,  and  of  a  cellular  texture, 
very  thin  in  the  intestines  and  in  the  iris.  The  distribution 
of  these  primitive  and  constituent  arterioles  and  of  these  parti- 
cular retractile  fibres  may  with  propriety  be  compared  (as  I 
intend  to  do  in  my  memoir  on  hemorrhagies,  see  Clin.  Chirurg. 
Vol.  III.)  to  the  threads  used  for  making  ropes  of  various 
thickness,  even  to  that  of  a  cable.  These  fibres  are  shortened 
in  consequence  of  the  engorgement  of  the  vessels  or  of  the 
afflux  of  blood  which  runs  through  them,  upon  the  same  prin- 
ciple on  which  a  ship's  rigging  at  a  certain  degree  of  exten- 

2  N 


298  Diseases  of  the  Eye. 

tension  is  shortened  to  a  greater  or  lesser  extent,  from  its 
becoming  soaked  by  some  fluid,  such  as  water.  It  is  by 
these  means  that  such  enormous  masses  as  vessels  of  war  are 
raised  from  the  ground  and  launched  afterwards  into  the  sea 
with  the  utmost  facility. 

In  order  to  prove  the  correctness  of  the  assertion  which  I 
have  just  made  upon  the  effects  of  the  contractility  occasioned 
by  the  afflux  of  the  blood  into  the  elementary  vessels  of  the 
motor  fibre,  it  will  suffice  to  observe  that,  when  a  muscle  is 
divided  transversely  near  the  origin  of  its  nutritious  or  organic 
firteries,  that  part  which  is  most  remote  from  it  will  be  no 
longer  susceptible  of  contraction.  The  same  thing  happens  to 
all  the  muscles,  whenever  the  arteries  going  there  have  been 
tied,  at  least  until  nature  shall  have  replaced  them  by  other 
vessels  by  which  a  new  circulation  may  be  established.  '<n 
other  respects  we  believe  that  the  afflux  of  blood  into  these 
linear  vessels  is  brought  about  through  the  agency  of  galvanic 
vital  excitations,  unknown  in  natg,re,  which  doubtless  proceed 
from  the  encephalic  nerves  to  the  organs  of  locomotion,  as 
well  as  from  those  of  the  ganglionic  system  to  the  muscular 
organs  of  internal  life. 

Of  Ophthalmia,  and  especially  of  the  Endemic  Ophthalmia 
of  Egypt. 

The  membrane  which  lines  the  interior  of  the  eye-lids  and 
the  surface  of  the  globe  of  the  eye  is  highly  susceptible  of 
inflammation  and  of  producing  ophthalmia,  a  disease  frequently 
quite  serious  and  very  obstinate;  but  in  this  article  we  shall 
almost  exclusively  confine  ourselves  to  that  species  which  we 
have  had  occasion  to  observe  in  Egypt,  because  it  possessed 
those  two  characteristics  in  the  highest  degree.  The  eyes 
having  been  struck  all  at  once  by  the  burning  light  of  the  sun, 
either  directly,  or  reflected  by  the  whitish  soil  of  that  country, 
and  having  been  moreover  exposed  there  to  the  effects  of  the 
suppression  of  the  cutaneous  perspiration,  an  obstinate  ophthal- 
mia, and  in  many  individuals  complete  blindness,  had  then 
resulted  from  those  circumstances. 

The  seat  of  the  ophthalmia  is  confined  to  the  vessels  of  the 


Egyptian  Ophthalmia.  299 

conjunctiva,  or  extends  deeply  to  those  of  all  the  coats  of  the 
eye,  including  even  those  of  the  iris.  Yet  this  inflammation, 
owing  to  the  organic  difference  which  distinguishes  that  part 
of  the  membrana  conjunctiva  lining  the  interior  of  the  eye- 
lids from  that  which  covers  the  ball  of  the  eye,  will  necessarily 
present  some  varieties,  according  to  its  being  located  in  one 
or  in  both  parts  of  this  membrane.  That  kind  which 
attacks  the  palpebral  conjunctiva,  and  which  occasions  the 
engorgement  of  the  numberless  vessels  of  this  species  of  mucous 
tissue,,  is  characterised  by  the  greater  or  lesser  intensity  of 
injection  or  redness  of  these  vessels;  the  sensation  of  paia 
accompanying  these  first  symptoms  is,  however,  less  lively 
than  when  inflammation  has  become  established  in  the  ocular 
conjunctiva,  A  degree  of  swelling  in  proportion  to  the  inten- 
sity of  the  disorder  is  subsequently  established  in  that  portion 
of  this  membrane  which  lines  the  internal  surface  of  the  eye- 
lids; a  purulent  exudation  takes  place  on  its  surface,  or  rather 
the  villous  extremities  of  its  vessels  exhale  or  transude  a 
peculiar  humour,  the  colour  and  consistency  of  which  will  be 
in  proportion  to  the  idiosyncrasy  of  the  individual  subjects,  or 
to  the  presence  of  the  virus  complicating  the  disease.  In  cases 
of  the  virus  being  of  a  syphilitic  nature,  the  symptoms  will 
assume  a  more  serious  character,  and  travel  much  more  rapidly; 
ophthalmia  displays  then  even  some  peculiar  features,  the  red- 
ness of  the  margin  of  the  eye-lids  is  clearer;  the  pus  discharged 
by  it  has  a  greenish  tint  as  in  gonorrhœa,  and  excoriates  the 
parts  with  which  it  comes  in  contact,  and  the  patient  suffers  a 
good  deal  during  the  night. 

The  tears  being,  on  account  of  the  inflammation,  unable  to 
reach  the  puncta  lachrymalia,  give  rise  to  an  almost  incessant 
weeping,  and  becoming  mixed  with  the  purulent  matter  fur- 
nished by  the  inflamed  vessels  of  the  palpebral  conjunctiva, 
augment  still  more  the  irritation  of  the  remainder  of  the  cye- 
ball  which  they  attack  by  their  corrosive  properties;  they  are 
the  cause  afterwards  of  ulcerations  on  the  transparent  cornea, 
the  progress  of  which  is  so  much  more  rapid  as  the  patients 
are  exposed  to  the  influence  of  a  hot  and  moist  season  or  cli- 
mate, and  as  this  moisture  is  saturated  with  deleterious  mias- 


300  Egyptian  Ophthalmia. 

mata,  or  with  alcoholic  gaseous  matter  which  is  evaporated 
from  different  sources  capable  of  producing  those  heterogeneous 
principles,  as  we  have  observed  in  several  instances.  In  fine, 
the  transparent  cornea,  being  highly  susceptible  of  the  opera- 
tion of  those  purulent  acrid  fluids,  is  very  prone  to  tear,  and 
is  sometimes  perforated  with  great  ease;  its  texture  being  of  a 
gelatinous  nature,  it  can  be  readily  dissolved,  particularly 
when  the  small  number  of  nervous  branches  distributed  to 
them  have  been  attacked  or  destroyed  by  any  cause  whatever, 
as  those  are  for  example  which  we  have  pointed  out.  This 
perforation  of  the  cornea  which  occurred  sometimes  in  Egypt 
all  at  once,  imparted  to  the  opththalmia  of  that  country  quite 
a  peculiar  character.  To  a  great  many  of  our  patients  it  hap- 
pened during  the  first  night  of  the  attack  of  the  disease,  when 
it  was  preceded  by  a  lively  and  sharp  j^ain,  and  by  deep  seated 
cephalalgia.  The  small  portion  of  the  transparent  cornea 
which  constituted  the  last  layer  of  the  ulceration,  burst  with  a 
kind  of  noise  similar  to  that  of  the  smacking  of  a  whip.  This 
cleft  has  appeared  to  us  to  be  the  result  of  the  rarefaction  of 
the  aqueous  humour,  occasioned  by  the  heat  of  the  season  and 
climate,  as  well  as  by  the  inflammation.  The  humour  made 
its  escape  outwards  together  with  the  membrane  containing  it, 
in  order  to  form  the  hernia;  the  tumour  then  was  of  a  dull 
gray  aspect,  but  was  of  a  darker  colour,  whenever  it  had  been 
formed  at  the  expense  of  the  iris.  The  one,  as  well  as  the 
other,  evinced  considerable  sensibility  on  coming  in  contact 
with  the  lightest  external  substances,  or  on  the  friction  of  the 
eye-lids.  Generally  speaking,  the  staphyloma  produced  by 
them,  diminished  by  degrees,  returned  into  the  anterior  cham- 
ber, and  the  membranes  resumed  their  original  position.  In 
this  case,  the  opening  of  the  transparent  cornea  would  be  closed 
by  the  sinking  of  its  borders  and  leave  a  small  opaque  and 
depressed  cicatrix  behind,  which  intercepted  only  at  first  the 
passage  of  the  rays  of  light.  In  other  instances  some  portion 
of  it  would  remain  outside  and  be  strangulated  by  the  closing 
up  of  the  opening,  lose  its  sensibility,  and  acquire  a  certain 
consistency,  or  rather  it  would  swell,  separate  into  several 


Egyptian  Ophthalmia.  301 

lobules,  and  assume  a  carcinomatous  character,  particularly  if 
it  had  been  complicated  ])y  a  venereal  taint. 

It  has  happened,  also,  under  certain  circumstances,  that  the 
capsule  of  the  crystalline  lens  had  been  ruptured  and  that  the 
latter  escaped  through  the  opening  of  tlie  cornea,  provided  its 
size  would  aliow  it  to  pass  out,  or  tiiat  it  fell  into  the  posterior 
or  anterior  chamber.  It  i-arely  happened  in  such  a  case  that 
the  eye  was  not  left  inflated,  because  the  membranes  being 
changed  and  subsequently  reduced  by  suppuration,  the  organ 
of  vision  became  completely  disorganized  and  lost  its  functions. 
The  same  distressing  result  has  been  observed  to  happen  to 
numerous  natives;  chiefly  to  indigent  persons  who  lie  almost 
naked  on  the  ground  and  in  the  open  airj  live  upon  improper 
food,  and  in  day-time  are  exposed  to  the  dust,  and  to  the 
burning  rays  of  the  sun,  against  which  they  make  no  kind  of 
exertion  to  protect  themselves.  There  were  also  a  conside- 
rable number  of  instances  of  this  kind  amongst  the  twenty-five 
whom,  after  the  first  year,  we  had  sent  back  to  France;  but 
these  unfortunate  men  were  unluckily  shipwrecked  on  the 
coast  of  Sicily,  and  every  one  of  them  drowned.* 

The  inflammation  of  the  ocular  conjunctiva  always  com- 
mences at  the  vessels  of  the  two  angles  of  the  eyes;  the  injection 
afterwards  spreads  gradually  or  suddenly  to  the  transparent 
cornea.  During  the  first  few  moments,  these  vessels  are  very 
distinct-  but  their  interstices  are  very  soon  filled  up,  and  the 
whole  surface  of  the  eye  is  covered  with  vessels  so  red  and 
swollen  that  they  frequently  produce  a  chemosis.  The  colour- 
inw  part  of  the  blood  ordinarily  becomes  stationary  at  the 
extremities  of  those  which  ramify  around  the  greater  periphery 
of  the  transparent  cornea.  Instances,  however,  occur  where 
the  proper  vessels  of  the  cornea,  or  rather  of  that  part  of  the 
conjunctiva  which  covers  it  (notwithstanding  the  extreme 
delicacy  of  this  membranous  expansion,  and  the  very  great 
ti"-htne'ss  of  its  adhesion)  become  injected,  and  standing  out  in 
bold  relief  before  this  cornea,  intercept  the  passage  of  the  rays 

»  The  convoy  of  these  blind  individuals  was  commanded  by  the  intendant 
jcommissary  in  chief,  Sucy. 


302  Egyptian  Ophthalmia. 

of  light.  Besides  the  majority  of  the  symptoms  already  descri- 
bed which  it  has  in  common  with  the  ophthalmia  of  the  palpe- 
bral conjunctiva,  it  causes  an  extremely  violent  local  pain, 
which  by  the  patient  is  attributed  to  the  presence  of  some 
grains  of  sand,  but  which  proceeds  from  no  other  cause  than 
from  those  injected  vessels.  This  pain  is  so  intense  that,  as 
has  been  observed  by  some  English  traveller,  it  is  as  if  the 
pupils  were  in  the  fire,  and  pricked  incessantly  with  pins. 
In  addition  to  this  there  are  then  always  dimness  of  sight  and 
intolerance  of  light.  The  coats  of  the  ball  of  the  eye  also 
become  more  promptly  involved  in  the  inflammation  than  in 
the  other  species  of  ophthalmia;  violent  pain  in  the  head,  ver- 
tigo, watchfulness,  fever,  sometimes  even  delirium;  such  are 
the  other  symptoms  which  manifest  themselves  and  contribute 
to  render  this  disease  more  or  less  serious. 

The  dilatation  of  the  vessels  of  the  ocular  conjunctiva,  we 
stated,  causes  more  intense  pain,  than  that  of  the  vessels  of 
the  palpebral  conjunctiva.  We  believe  that  this  difference  is 
owino"  to  the  circumstance  that  the  fascicles  of  the  long  ciliary 
nerves  furnish  a  large  number  of  twigs  which,  cross  the  sclero- 
tica near  the  transparent  cornea,  reach  as  far  as  the  surface  of 
these  organs,  and  finally  lose  themselves  in  that  part  of  the 
conjunctiva  by  which  they  are  covered;  and  as  these  nerves 
are  furnished  by  the  lenticular  ganglia  which  belong  emphati- 
cally speaking  to  the  great  sympathetic,  however  slight  any 
injury  of  this  system  of  the  nerves  may  be,  it  is  invariably 
accompanied  by  pain  infinitely  more  keen  and  lively  than  that 
belonging  to  the  nerves  of  the  life  of  relation.  The  latter  are 
principally  those  which  supply  that  part  of  the  conjunctiva 
which  lines  the  internal  surface  of  the  eye-lids. 

We  have  observed  that  the  first  species  of  ophthalmia,  or  that 
which  almost  exclusively  attacks  the  palpebral  conjunctiva, 
was  commonly  the  result  of  the  suppression  of  a  diarrhoea,  of 
a  discharge,  or  of  some  eruption  having  existed  previously 
somewhere  on  the  surface  of  the  body.  This  kind  of  distem- 
per was  likewise  more  frequent,  particularly  in  Egypt,  in 
those  seasons   and   low  and  damp  places  in    which   it   was 


Egyptian  Ophthalmia.  303 

kept  up  by  gaseous  emanations  of  a  more  or  less  irritating* 
and  mephilic  nature. 

The  second  species  of  ophthalmia,  or  that  which  almost  sud- 
denly attacks  the  ocular  conjunctiva,  and  which  results  in 
engorgement  and  intense  redness  of  the  bloodvessels  of  this 
part  of  the  membrane,  has  for  its  predisposing  causes  the  action 
of  the  fiery  light  of  the  sun,  the  refraction  or  reverberation  of 
the  burning  sands  of  the  desert,  and  the  immoderate  use  of 
alcoholic  liquors,  such  as  the  whiskey  of  the  country. 

Amongst  the  plagues  with  which,  for  about  six  weeks,  we 
had  been  afflicted  in  Egypt,  we  may  find  another  additional 
cause  of  this  ocular  ophthalmia,  particularly  in  children  of  the 
lower  orders,  who  are  there  extremely  subject  to  it,  and  who 
are  almost  all  attacked  by  it,  in  the  presence  and  bites  of  the 
musquitoes,  insects  which  under  certain  atmospheric  circum- 
stances multiply  to  such  an  extent  that  we  were  obliged  to 
shake  our  clothes,  as  we  shake  ofi"  the  dust.  In  some  districts 
there  are,  moreover,  such  quantities  of  locusts  that  the  wind 
drove  and  piled  them  up  by  myriads  in  hollow  places,  where 
by  putrefaction  they  became  one  of  the  sources  of  the  epidemic 
ophthalmije  which  we  have  observed  there.  With  the  excep- 
tion of  mechanical  agencies  which  will  operate  directly  upon 
the  tissues  of  the  organ  of  vision,  it  is  in  all  cases  very  evident 
that  the  essential  and  exciting  cause  of  both  species  of  ophthal- 
mia which  have  just  been  discussed,  may  be  traced  back  to  a 
suppression  of  the  cutaneous  perspiration,  occasioned  by  the 

*  On  my  journey  to  Thorn,  in  June  1812,  while  on  our  march  to  Russia,  I  had 
been  compelled  to  sleep  on  a  bundle  of  straw  in  the  bar-room  of  a  tavern,  where 
during  the  whole  night  a  great  deal  of  whiskey  (schnaps)  had  been  consumed, 
and  was  greatly  surprised  on  my  waking  at  break  of  day,  to  have  been  attacked 
with  an  ophthalmia  which  prevented  me  not  only  from  distinguishing  any  objects, 
but  almost  from  seeing  the  light.  Independent  of  this  serious  accident,  I  found 
myself  at  the  same  time  in  a  certain  state  of  intoxication  which  I  could  ascribe 
only  to  the  alcoholic  vapours  with  which  the  apartment  in  which  I  had  been 
accommodated  for  the  night,  had  been  filled  without  my  being  aware  of  it.  Two 
cups  applied  to  the  temples,  lotions  of  tepid  water  with  a  small  addition  of  Gou- 
lard water,  the  open  air  and  the  exercise  on  horseback  which  I  was  compelled  to 
take  in  order  to  follow  the  movements  of  the  army  (being  conducted  by  my 
servant),  were  sufficient  promptly  to  subdue  this  disorder. 


304  Egyptian  Ophthalmia. 

sudden  changes  from  a  very  higli  temperature  in  day  time  to 
its  usually  very  low  slate  during  night,  more  especially  in 
damp  places. 

To  the  above  causes  combined,  and  lo  their  operation  alone, 
but  not  to  a  contagious  principle,  is  therefore,  the  serious  and 
obstinate  ophthalmia  to  be  ascribed,  which  prevailed  in  Egypt 
amongst  the  French  and  foreign  troops  who  occupied  that 
beautiful  country,  during  the  years  179S,  1799,  1800  and 
ISOl.  I  therefore  deem  it  incumbent  upon  me  to  record  here 
my  opinion  upon  this  subject,  illustrated  already  by  Doctor 
Fournier,  in  his  translation  of  Scarpa's  treatise  on  the  diseases 
of  the  eyes,  from  the  notes  and  observations  which  I  had  com- 
municated to  that  learned  physician. 

Many  of  the  English,  Dutch,  Prussian  and  Bavarian 
physicians  have  maintained,  and  maintain  still,  that  the  oph- 
thalmia which  has  prevailed  amongst  the  troops  of  these 
nations,  during  their  occupation  of  the  frontiers  of  France  in  the 
damp  and  low  districts  of  Picardy,  Flanders  and  the  Palatinate, 
during  the  years  1816  and  1S17,  had  been  contagious,  and 
that  this  disease  had  grown  out  of  the  ophthalmia  of  Egypt 
(according  to  the  same  physicians  contagious  likewise),  which 
the  troops  composing  the  army  of  the  East  had  brought  with 
them  from  that  ancient  part  of  the  world,  where  it  is  endemic. 

Notwithstanding  all  the  objections  which  we,  the  Baron 
Desgenettes  and  myself,  were  enabled  to  oppose,  M.  Roux, 
on  the  occasion  of  reading  his  report*  before  the  Medical 
Society  of  the  Faculty,  made  us  not  only  acquainted  with  the 
opinion  suggested  by  the  English,  but  told  us  that  he  had  fully 
adopted  it  himself,  and  stated  in  that  printed  account  that  this 
opinion  gained  ground  and  was  believed.  Now,  the  interests 
of  science  and  public  tranquillity  indispensably  require  to  cor. 
rect  this  error,  and  to  prove  that  the  disease  bears  not  the 
slightest  contagious  character.  Gonorrhœal  ophthalmia  with 
purulent  discharge  may  be  comm.unicated  by  the  immediate 
transmission  of  the  purulent  fluid  from  a  diseased  person  to 


*  Voyage  fait  on  Angleterre  en  1814,  ou  Parallèle  de  la  Chirurgie  Angloise 
avec  la  Chirurgie  Françoise.     Par  M.  P.  I.  Roux.     Trans. 


Egyptian  Ophthalmia.  305 

the  internal  margin  of  the  eye-lid  of  a  healthy  individual;  and 
that  is  the  only  species  of  infection  which  may  be  urged  to 
exist.  Any  other  way  of  communication  cannot  be  proved 
and  does  not  exist;  reason  and  experience  both  demonstrate  it 
to  be  impossible. 

Two  circumstances  seem  to  us  to  have  led  to  the  belief  in 
the  existence  of  miasmatic  contagion,  as  insisted  upon  by  the 
physicians  alluded  to:  first,  the  rapid  and  general  propagation 
of  the  disease  from  the  soldiers  first  attacked  by  it  to  the 
troops  occupying  the  same  places,  or  even  dwellings;  secondly, 
the  recurrences  of  this  disorder  in  those  who  had  been  cured 
of  it,  by  communication  or  frequent  intercourse  which  they 
had  with  those  who  were  afiected  with  it. 

With  the  view  to  reply  to  these  conjectures,  which  run  into 
one  another,  I  would  observe  that,  instead  of  ascribing  this 
ophthalmia  to  the  passage  of  morbid  miasmata  from  the  diseased 
eyes  of  some  individual  to  the  sound  ones  of  another — an 
event  also  in  other  respects  not  merely  improbable,  but  even 
impossible,— its  development  in  the  latter  as  well  as  in  the 
former,  in  spite  of  the  appearances  of  this  contagion,  cannot  be 
referred  to  any  other  causes  than  to  the  deleterious  influence 
of  the  climate,  or  rather  to  the  remarkable  changes  which  the 
seasons  have  undergone,  more  especially  in  the  western  coun- 
tries of  Europe,  during  the  years  of  the  occupation  (of  the 
frontiers  of  France)  in  181 G,  17  and  18.  Indeed,  these 
singular  and  uncommon  changes  have  imparted  to  the  climate 
of  those  countries  a  character  similar  to  that  which  the  climate 
of  Egypt  and  of  other  regions  along  the  coast  of  Africa  possesses, 
where  ophthalmia  is  endemial  without  being  contagious.  It 
appears  to  me  to  be  clearly  demonstrated  that  during  the  sum- 
mers of  the  two  last  years  the  atmospheric  constitution,  more 
especially  in  the  low  and  damp  districts  of  Flanders,  of 
Picardy,  Alsace  and  the  Palatinate,  or  along  the  banks  of  the 
larger  rivers,  has  displayed  features  similar  to  those  of  Egypt 
for  instance.  Thus  the  thermometer  rose  in  the  parts  of 
Europe  just  named,  in  day-time  at  noon,  and  under  the  influ- 
ence of  southerly  or  south-easterly  winds,  to  25°  or  27° 
2  0 


306  Egyptian  Ophthalmia. 

(Reaumur),*  whilst  at  night,  by  northerly,  north-westerly  or 
north-easterly  winds,  it  fell  to  11°  and  even  to  9°.t  (Now  this 
is  absolutely  the  character  of  the  climate  of  Egypt.  Compare 
on  this  subject  my  ^^  Relation  Chirurgicale  de  V Armée 
d'' Orient,  Articles  Ophthalmie,  Classification  des  Saisons, 
Src.^') 

After  this  it  will  be  easily  understood,  how  the  cantonments, 
encampments  or  bivouacs  of  the  soldiers  of  the  army  of  occu- 
pation, on  a  soil  reduced  to  powder,  and  more  or  less  arid  after 
harvest  time,  the  daily  maneuvres  of  the  troops  and  the  re- 
verberation  of  the  sun  upon  the  whitish   soil  during   those 
seasons,  burning  as  they  were,  in  Egypt,  must  have  predis- 
posed the  organ  of  sight  to  an  irritation  which  afterwards  excit- 
ed the  immediate  cause  of  the  ophthalmia,  that  is  to  say,  the 
sudden  suppression  of  cutaneous  perspiration,  effected  by  the 
quick  transition  from  the  burning  heat  of  day  to  the  icy  cold- 
ness of  the  night,  whilst  the  thermometer  fell  to  9°  and  8°. 
The  consequences  of  these  transitions  must  be  so  much  more 
sensibly  felt,  as  a  copious  miasmatic  moisture  prevailed  simul- 
taneously, which  the  emanations  from  the  sea,  lakes,  ponds 
and  rivers  of  those  low  countries  perpetually  produce,  and 
which  the  coldness  of  the   nights  condenses  and  precipitates 
upon  any  thing  with  which  the  soil  is  covered.     Now  the 
soldiers  exposed  to  the  action  of  the  air,  without  the  precau- 
tions requisite   to  meet  those  sudden  changes,  the  nature  of 
which  is  unknown  to  them,  must  necessarily  be  subject  to 
the  deleterious  effects  of  these  atmospheric  vicissitudes.     The 
same  has  happened  also  to  others  who  did  not  take  the  neces- 
sary precautions;  and  that  they  had  been  neglected  we  know 
from  the  statements  we  have  received  from  numerous  indivi- 
duals.    The  disease  had  become  epidemic  and  seemed  to  have 
a  contagious  appearance,  because  these  pernicious  atmospheric 
influences  extended  and  penetrated  every  where.     Thus,  for 
example,  the  sick,  the  wounded  or  the  fever  patients  of  a  hos- 
pital or  of  an  ambulance,  the  windows  of  which  had  not  been 

*  From  88"  to  93'  by  Fahrenlreit's  thermoineler.     Trans. 
\  From  8°  to  12°  Fahrenheit.     Trans. 


Egyptian  Ophthalmia.  307 

carefully  shut  daring  the  night;  again,  those  who  were  not 
compelled  to  cover  themselves  with  a  blanket  or  to  keep  a 
warm  night-cap  on  their  heads,  were  attacked,  as  we  have 
seen  it  in  our  own  soldiers  in  the  hospitals  of  Cairo,  by  an 
ophthalmia  which  was  most  unreasonably  attributed  to  contagion, 
proceeding,  as  was  supposed,  from  some  individuals  who  by 
chance  had  been  admitted  into  the  wards  of  these  ambulances 
at  the  same  time,  when  the  causes  foreign  to  such  contagion, 
expended  their  utmost  violence  upon  the  other  patients.  To 
several  English  physicians  who,  at  the  commencement  of  the 
year  1818,  came  to  Paris  to  consult  me,  on  account  of  this 
affection,  I  proposed  to  substantiate  these  facts  which  I  had 
witnessed  myself.  On  the  other  hand,  the  regimen  and 
method  of  treatment,  almost  purely  local,  which  had  been  put 
into  practice,  in  consequence  of  the  mistakes  committed  with 
respect  to  the  true  causes  of  the  disease,  have  not  a  little  con- 
tributed to  aggravate  and  to  propagate  it. 

But  what  proves  still  further  the  correctness  of  my  assertion, 
respecting  the  ophthalmia  which  had  prevailed  in  Europe, 
amongst  the  troops  of  the  army  of  occupation,  is  that  the  staff  and 
other  officers  who  were  well  lodged,  well  clothed  and  accustomed 
by  the  force  of  education  and  close  reasoning,  to  observe  the 
precepts  of  dietetics  better  than  private  soldiers,  had  been 
generally  exempt  from  this  disease,  although  the  very  same 
officers,  as  well  as  the  medical  officers,  freely  communicated 
with,  and  were  constantly  in  the  midst  of,  these  diseased  or 
healthy  soldiers.  I,  of  course,  always  except  from  this  oph- 
thalmia, that  species  which  has  been  occasioned  by  the  reper- 
cussion of  a  gonorrhœal  discharge,  which  is  quite  common 
amongst  the  English,  because  of  their  physicians  treating  the 
urethral  running  by  means  of  astringent  injections.  The 
dampness  of  the  climate  of  Great  Britain  is,  moreover,  very 
well  calculated  to  favour  the  development  of  ophthalmia, 
and  to  keep  it  up. 

In  Egypt,  also,  we  might  have  been  warranted  to  believe 
that  the  ophthalmic  patients  communicated  their  disorder  to 
our  wounded  with  whom  they  were  promiscuously  treated  in 
the  same  wards,  as,  indeed,  the  ophthalmia  appeared  in  the 


308  Egyptian  Ophthalmia. 

latter  about  the  same  time,  and  travelled  with  the  same  rapid- 
ity. But  we  soon  perceived  that  they  were  indebted  for  the 
disease  of  their  eyes  to  the  same  causes  which  had  produced 
it  in  the  former,  that  is  to  say,  to  the  suppression  of  the  cuta- 
neous perspiration.  At  first  our  hospitals  were  destitute  of 
the  necessary  furniture,  especially  of  cover-lids,  and  the  sol- 
diers besides  being  not  at  all  accustomed  to  the  extreme  heat 
of  the  climate,  would  not  submit  to  be  covered  up  at  night; 
but  as  soon  as  they  learnt  how  to  take  the  proper  precautionary 
measures,  and  as  soon  as  we  had  obtained  the  necessary  cover- 
lids and  caps  to  cover  our  patients  and  to  protect  our  soldiers 
against  the  action  of  the  night  air,  the  ophthalmia  disappeared. 
An  ophthalmic  patient  was  lodged  beside  another  person  whose 
eyes  were  in  a  healthy  condition;  as  long  as  the  latter  was 
sheltered  from  the  chilliness  and  dampness  of  the  night  air  his 
eyes  remained  sound.  Those  whose  ophthalmia  had  assumed 
a  chronic  character  and  who  took  it  with  them  to  France,  for 
the  same  reason  never  communicated  it  to  their  countrymen. 
We  have  met  with  them  in  our  hospitals  or  in  the  Hotel  of  the 
Invalids,  mixing  with  other  persons  or  with  the  soldiers  of 
other  regiments,  whilst  the  supposed  contagion  never  could  be 
detected.  It  is  wrong,  therefore,  to  attribute  to  the  propagation 
and  transmission  of  this  disease,  the  epidemic  ophthalmias 
which  have  sincethat  broken  out  in  different  countries  of  Europe 
and  in  different  seasons.  We  may  then  infer  from  all  these 
facts,  that  without  the  immediate  application  of  the  puriform 
matter  from  the  eyes  of  an  ophthalmic  person  to  those  of  a 
healthy  individual,  as  we  have  before  stated,  no  contagion  can 
take  place,  unless  the  eyes  of  the  latter  (supposing  them  to  be 
very  irritable)  approach  those  of  the  patient  near  enough  to 
receive  almost  immediately  the  gaseous  molecules  of  the  puru- 
lent tears  of  the  former. 

Several  celebrated  physicians  of  Germany  and  England, 
being  convinced  also  of  the  truth  of  the  assertions  just  made 
by  me,  have  written  no  doubt  in  a  more  luminous  manner  and 
entered  more  into  details,  concerning  the  errors  into  which 
the  advocates  of  the  theory  of  contagion  have  fallen.  Pro- 
fessor Baltz,  surgeon  in  chief  to  the  royal  Prussian  guards. 


Egyjitian  Ophthalmia.  S09 

has  published  at  Berlin,  in  1824,  in  the  sense  of  our  own 
views,  a  work  which  has  been  crowned  by  the  Academy  of 
Utrecht,  and  which  he  had  undertaken  in  reply  to  a  question 
on  the  subject  of  this  matter. 

Nevertheless  it  is  possible  that  the  miasmatic  emanations, 
exuding  from  inflamed  or  ulcerated  surfaces  of  the  eyes  or 
eye-lids,  being  carried  to  a  certain,  and  of  course  very  short 
distance,  may  produce  an  affection  of  the  same  kind  in  the 
eyes  of  a  pretty  healthy  individual,  who  might  happen  to  be 
in  this  part  of  infected  atmosphere,  according  to  the  suscepti- 
bility or  extreme  irritability  of  the  organs  of  sight  of  such  a 
person.  If,  indeed,  we  direct  for  one  moment  our  attention 
to  the  vital  properties  of  the  ocular  and  palpebral  conjunctiva, 
we  must  become  impressed  with  the  conviction  that  this 
membrane  is  liable  to  a  greater  or  lesser  degree  of  irritation 
and  inflammation,  in  proportion  always  to  individual  idiosyn- 
crasies, upon  coming  in  immediate  contact  with  certain  sub- 
stances or  certain  liquids,  which  otherwise  produce  no  parti- 
cular effect  whatever  upon  other  organs  apparently  more 
irritable  and  more  delicate,  such  as  for  instance  the  mucous 
membranes  of  the  viscera,  while  these  become  violently 
irritated  by  substances  which,  in  their  turn,  produce  no  im- 
pression upon  the  conjunctiva;  this,  however,  is  highly  sus- 
ceptible to  the  impressions  made  by  different  degrees  of 
temperature.  Thus,  for  example,  the  men  who  in  Egypt 
superintend  the  chicken  oven,  regulate  the  heat  of  these  ovens 
by  the  changes  which  that  membrane  undergoes,  with  as 
much  precision  as  if  they  made  use  of  a  thermometer,  and 
these  impressions  are  made  upon  those  persons  with  so  much 
accuracy  and  regularity,  that  they  rarely  differ  half  a  degree 
or  one  degree  at  most  from  that  instrument. 

We  might  again  allege  our  own  example  as  an  instance  of 
the  possibility  of  an  ophthalmia  instantaneously  developed,  by 
coming  in  contact  with  certain  miasmatic  effluvia  of  an  infected 
and  irritating  character  at  the  distance  of  a  few  inches  only: 
the  following  fact  will  confirm  the  truth  of  this  assertion, 
without  militating  against  that  already  insinuated. 

One  Bonneau,  27  years  of  age,  a  private  of  the  sixth  regiment. 


310  Egyptian  Ophthalmia. 

of  infantry  of  the  guards,  previously  to  his  entering  the  mili- 
tary service,  and  while  he  was  employed  as  a  journeyman 
butcher,  had  been  directed,  in  1814,*  by  the  master  of  the 
shambles  to  skin  and  to  open  a  cow  which  was  suspected  to 
have  died  of  a  carbuncle.  No  sooner  had  the  first  incision 
been  made  into  the  belly,  when  this  young  man  was  suddenly 
seized  with  vertigo  and  instantaneous  loss  of  vision.  He  de- 
clared  to  have  felt  a  very  sensible  and  sudden  impression, 
made  upon  his  face  by  a  warm  vapour  of  an  offensive  smell, 
which  had  become  disengaged  from  the  abdominal  cavitv  of 
the  animal. 

These  primary  effects  were  succeeded  by  an  acute  ophthalmia 
of  a  purulent  nature,  which  continued  to  exist  in  different 
degrees  until  the  year  1824,  as  well  as  an  eruption  of  small 
furunculous  excrescences  which  had  made  their  appearance 
in  various  places  of  the  face  during  the  first  twenty-four  hours. 
This  man,  who  had  never  been  affected  either  with  syphilis, 
or  psora,  or  any  other  herpetic  disorder,  had  to  undergo  a 
variety  of  treatments  to  rid  himself  from  these  complaints. 
The  ophthalmia  alone  proved  obstinate  and  became  in  the 
sequel  complicated  by  an  abnormal  dilatation  of  the  pupils  and 
a  remarkable  irregularity  in  the  perception  of  diminutive 
objects. 

We  succeeded,  however,  in  re-establishing  the  functions  of 
these  organs  by  making  use  for  some  time  of  revulsives  and 
of  an  anti-ophthalmic  pomatum,  as  well  as  by  the  application  of 
cleansing  and  slightly  camphorated  collyria,  the  formula  for 
which  will  be  given  below. 

I  shall  now  return  to  the  description  of  ophthalmia,  and  point 
out  the  treatment  which  has  appeared  to  me  to  be  most  ser- 
viceable. 

Among  the  terminations  of  this  disease  hypopion  is  but  of 
rare  occurrence.  It  announces  itself  as  an  opaque  point  at  the 
transparent  cornea  which  deranges  the  passage  of  the  optic 
cone.  This  point  increases  by  degrees,  protrudes  from  the 
surface  of  the  eye,  and  occupies  a  space  of  more  or  less  extent 

*Thi3  happened  during  the  occupation  of  Paris  by  the  foreign  troops. 


Egyptian  Ophthalmia.  311 

Upon  the  cornea,  the  laminae  of  which  become  detached  from 
one  another.  Hypopion  is  distinguished  from  opacity  or 
albugo  by  a  sliglit  fluctuation  which  may  be  easily  ascertained 
■with  the  assistance  of  the  extremit}''  of  a  probe. 

When  the  person  is  of  an  irritable  habit  of  body  and  the 
ophthalmia  of  long  standing,  the  engorgement  of  the  conjunc- 
tiva is  often  very  considerable;  this  membrane  forms  a  circular 
eminence  around  the  cornea  and  gets  beyond  the  eye-lids; 
these  again  are  turned  downwards,  swell,  and  present  the 
utmost  resistance  to  their  reduction. 

The  tarsi  cartilages  rarely  participate  in  this  species  of  in- 
flammation. But  when  they  do,  the  lachrymal  ducts  situated 
in  the  midst  of  them  are  destroyed  in  consequence  of  the  sup- 
puration commonly  resulting  from  it;  the  eye-lids  lose  their 
shape  and  shrink.  Owing  to  consecutive  inflammation  super- 
vening upon  the  globe  of  the  eye,  loss  of  sight  almost 
invariably  takes  place  afterwards.  Of  this  I  have  witnessed 
several  examples. 

In  fine,  ophthalmia  weakens  the  organ  of  sight,  predisposes 
to  cataract,  to  fistula  lachrymalis,  to  amaurosis,  and  is  not 
seldom  succeeded  by  nyctalopia.^' 

While  in  Egypt  I  have  had  repeatedly  occasion  to  notice 
that  ophthalmia,  which  more  frequently  occurs  there  during 
the  inundation  of  the  Nile  than  during  any  other  season,  more 
frequently  attacked  persons  of  light  than  of  dark  complexion, 
and  that  then  the  right  eye  was  also  more  seriously  aflected 
than  the  left;  for  almost  all  those  who  have  become  blind  of 
one  eye,  are  so  on  the  right  eye.  This  may,  perhaps,  depend 
on  the  habit  of  twinkling  with  the  left  eye,  whenever  a  glar- 
ing light  strikes  it,  whilst  the  right  eye  is  more  willing  to 
brave  it;  it  may  perhaps  be  referred  also  to  the  custom  which, 
generally  speaking,  all  persons  indulge  themselves  in  of  lying 
on  the  right  side,  so  that  this  part  of  the  body  is  the  first  to 
receive  the  impressions  of  dampness  from  the  soil. 

*  la  cases  of  nyctalopia  and  gutta  serena  we  have  successfully  employed  the 
moxa,  by  applying  it  to  the  course  of  the  principal  branches  of  the  facial  (lesser 
sympathetic)  nerve. 


312  Egyptian  Ophthalmia. 

Whenever  ophthalmia  has  not  been  neglected,  and  it  is 
treated  according  to  the  principles  of  surgery,  it  is  not  attended 
by  distressing  consequences:  but  the  blind  confidence  of  the 
soldier  in  the  remedies  of  mountebanks,  his  neglecting  to  re- 
pair to  the  hospitals,  and  the  little  exactness  with  which  at 
first  he  attends  to  the  regimen  prescribed  to  him,  frequently 
render  every  care  abortive. 

In  the  two  species  of  ophthalmia  which  I  have  described, 
whatever  may  have  caused  them,  when  they  are  accompanied 
by  redness  and  a  sensible  engorgement  of  the  vessels  of  the 
eye,  depletory  measures  are  indicated,  such  as  depletion  from 
the  arm  or  foot,  still  better  from  the  temporal  artery,  and  cups 
applied  to  the  temples,  to  the  nape  of  the  neck  and  between 
the  shoulders.  These  measures,  which  ought  to  be  repeated, 
according  to  the  plethoric  condition  of  the  person,  and  accord- 
ing to  the  intensity  of  the  inflammation,  should  be  followed  up 
by  stimulating  pediluvia,  by  steaming  the  diseased  eye  with 
the  vapour  of  a  boiling  decoction  of  some  emollient  and 
anodyne  articles,  by  lotions  made  of  a  strong  decoction  of  lin- 
seed, and  poppy  heads,  with  the  addition  of  a  small  quantity 
of  belladonna,  taking  care  to  apply  them,  as  much  as  possible,  to 
the  intermediate  space  of  the  eye-lids,  for  when  applied  exter- 
nally they  are  apt  to  increase  the  oedema;  poultices  particularly 
have  this  inconvenience,  independent  of  the  restraint  and 
weight  which  they  exert  upon  the  eye. 

A  paste  (une  étoupade),  made  of  the  white  of  some  eggs, 
beaten  up  with  a  few  drops  of  rose-water,  and  with  a  few 
grains  of  sulphate  of  alumine  and  of  camphor,  applied  in  the 
evening  over  the  eyes,  allays  the  pain  and  diminishes  the  in- 
flammation. 

The  effects  of  these  topical  applications  maybe  promoted  by 
directing  the  patient  to  take  cooling  and  mucilaginous  drinks 
internally,  and  by  giving  him  during  the  night  several  glasses 
of  an  anodyne  emulsion;  a  suitable  regimen  should  also  be 
prescribed,  perspiration  be  kept  up,  and  the  light  shut  out  from 
him. 

As  the  inflammation  diminishes  and  the  vessels  become  un- 
loaded, coUyria  strengthened  by  a  few  drops  of  acetate  of  lead 


Egyptian  Ophthalmia.  313 

in  solution,  or  by  a  solution  of  tartarized  antimony,  mixed 
with  a  proportionate  quantity  of  distilled  water  of  opium, 
gradually  to  be  augmented,  may  subsequently  be  used.  When 
resolution  has  commenced,  a  decoction  of  the  rind  of  pome- 
granate, or  a  weak  solution  of  sulphate  of  zinc,  may  then  be 
employed.  The  temperature  of  these  various  collyria  ought 
to  be  raised  to  25°  or  30°  of  Reaumur's  thermometer  (or  from 
88°  to  101°  of  Fahrenheit). 

If  the  engorgement  of  the  conjunctiva,  however,  proves 
obstinate,  and  this  should  be  swollen,  a  few  scarifications  may 
be  made  with  the  lancet;  or  the  most  projecting  points  may 
even  be  cut  off. 

When  the  eye-lids  are  turned  down  and  form  a  circular 
eminence  around  the  eye,  a  few  scarifications  may  be  made  at 
first  in  the  direction  of  the  eye-lid,  carefully  avoiding  to 
wound  the  tarsi  cartilages;  astringent  collyria  may  also  be  used 
for  a  few  hours,  and  subsequently,  as  we  have  already  men- 
tioned, the  reduction  of  the  eye-lids  may  be  made,  with  the 
precaution  to  rub  them  with  a  little  cerate  and  not  to  wound 
the  eye-ball;  they  are  then  to  be  put  again  in  their  place  by 
means  of  a  bandage,  and  the  patient  should  be  directed  to  keep 
himself  perfectly  quiet.  This  mode  of  treatment  has  invaria- 
bly succeeded  with  me,  but  requires  a  little  practice. 

If,  however,  these  measures  should  prove  inadequate,  the 
exuberant  growth  of  the  conjunctiva  must  be  extirpated,  tak- 
ing care  to  save  the  tarsi  cartilages,  as  much  as  possible;  the 
eye-lid  will  thereby  be  reduced  and  afterwards  assume  its 
original  shape. 

Although  the  remedies  hitherto  described  may  suit  alike 
both  species  of  ophthalmia,  still,  whenever  this  affection  is 
almost  exclusively  seated  in  the  palpebral  conjunctiva,  so  that 
it  might  be  denominated  catarrhal  ophthalmia,  it  will  be 
proper,  immediately  after  having  made  a  sufficient  sanguineous 
depletion,  to  have  recourse  to  emetics  under  observance  of  all 
the  requisite  precautions,  and  to  gentle  purgatives,  to  be  re- 
peated according  to  circumstances;  if,  on  the  contrary,  the 
ophthalmia  has  its  seat  in  the  ocular  conjunctiva,  it  will  be  of 
service  to  persevere  longer  than  in  the  other  species  with  the 
2  P 


314  Egyptian  Ophthalmia. 

revulsive  capillary  depletions,  with  the  cooling  and  sedative 
drinks,  with  the  privation  of  light,  and  with  the  use  of 
anodyne  and  gently  repellent  cnllyria. 

Ulcers  of  the  eye-lids  are  to  be  treated  with  desiccant  sub- 
stances and  mild  escharotics.  We  have  in  this  case  success- 
fully employed  a  gentle  cautery  with  the  nitrate  of  silver  and 
a  pomatum  of  the  following  formula: 

Take  of  cerate,  made  of  virgin  wax  and  oil  of  sweet  almonds,  1  oz. 

Red  oxide  of  mercury,  ground  and  purified,  .  4  grs. 

Prepared  tutty,  16  grs. 

Camphor  dissolved  in  the  yolk  of  an  egg,  4  grs. 

Paste  of  cochineal,  8  grs. 

Saffron  in  powder,  6  grs. 

Mix  and  triturate  in  a  marble  mortar. 

Avery  small  quantity  of  this  pomatum  may  be  put  at  night, 
before  going  to  bed,  along  the  margin  of  the  ^eye-lids,  after 
which  the  eyes  are  to  be  covered  with  a  cloth  not  very  tightly 
applied. 

The  cure  of  ulcers  of  the  cornea  and  of  albugoes  should 
never  be  thought  of,  until  the  inflammation  of  the  cornea  has 
been  completely  removed.  Fumigations  with  the  red  oxide 
of  mercury,  and  the  immediate  application  of  some  mild  caus- 
tic, will  usually  be  sufficient  to  cause  them  to  disappear;  besides 
which  it  will  almost  always  be  necessary  to  establish  issues 
upon  the  sides  of  the  neck,  between  the  mastoid  processes 
and  the  occipital  protuberances.* 

The  seton,  painful  and  very  troublesome  as  it  is,  is  danger- 
ous also,  and  has  appeared  to  me  to  aggravate  the  complaint. 

There  is  no  occasion  for  any  attempt  to  cause  the  staphy- 
lom.a  to  recede,  during  its  growth:  nature  herself  must  first 
have  begun  its  reduction,  when  she  may  afterwards  be  assisted 
merely  by  a  little  pressure  properly  made.     If  the  tumour 

**  If  the  opacity  should  be  of  a  certain  degree  of  thickness,  it  may  be  lifted  up 
in  small  laminae  with  a  very  fine  bistoury.  I  have  had  occasion  to  perform  this 
operation  in  the  case  of  a  young  lady  at  Toulon;  which  measure  materially  con- 
tributed towards  the  destruction  of  an  albugo  of  long  standing  which  covered 
the  whole  cornea,  and  intercepted  entirely  the  passage  of  light.  Its  transparency 
was  restored  in  that  part  which  I  had  made  thinner  with  the  bistoury,  and  in  the 
course  of  time  this  individual  was  enabled  to  discern  any  objects  quite  clearly. 


1 


Egyptian  Ophthalmia.  315 

loses  its  sensibility  and  should  remain  stationary  outside,  it 
must  then  be  extirpated  with  a  pair  of  curved  and  flattened 
scissars,  I  have  never  had  occasion  to  perform  this  operation 
more  than  twice;  the  organ  of  vision  had  in  both  these  cases 
partially  resumed  the  performance  of  its  functions. 

Where  the  ophthalmia  is  kept  up  by  a  venereal  taint,  it  is 
indispensable  to  remove  its  cause  by  the  use  of  anti-syphilitic 
remedies  to  be  taken  internally,  especially  by  the  sudorific 
and  cleansing  syrups,  with  which  a  proportionate  quantity  of 
oxy-muriate  of  mercury  may  be  combined.  Mercurial  frictions 
should  likewise  be  made  to  the  soles  of  the  feet  and  at  great 
intervals  from  each  other.  If  it  has  resulted  from  suppression 
0Î  i\\e  gonorrheal  discharge,  the  local  irritation  may  be  sub- 
dued by  scarifying  the  temples,  by  anodynes,  and  by  the  intro- 
duction into  the  urethra  of  a  gum  elastic  bougie,  besmeared 
with  a  coat  of  opium.  If  these  measures  will  not  produce  the 
desired  effect,  another  gonorrhœa  might  be  inoculated  with 
advantage,  or  an  alkaline  injection  might  be  made  into  the 
canal  of  the  urethra. 

When  ophthalmia  is  of  a  purely  gastric  origin,  bleeding  is 
not  at  all  indicated;  cupping  with  the  scarificator  is  sometimes 
required;  and  incisions  into  the  eye-lids,  if  they  are  oedematous, 
may  be  of  service.  Warm  wine  and  repellent  collyria  should, 
indeed,  be  applied  immediately;  but  for  the  affection  of  the 
stomach,  the  patient  should  be  prevailed  on  to  take  some  mild 
emetics,  followed  up  by  some  bitter  draughts.  If  the  disease 
should  not  yield  to  these  means,  the  establishment  of  issues 
upon  the  sides  of  the  neck,  or  behind  the  ears,  will  be  required. 
Deep  seated  and  remarkable  organic  changes,  detected  in 
the  course  of  autopsical  examinations,  may  be  the  results  of 
ophthalmia.  I  have  been  enabled  to  convince  myself  fully  of 
this  after  the  fatal  issue  of  the  disease  of  M.  Poireé,  brigadier 
of  the  guides  of  the  army  of  the  East.  This  individual,  while 
performing  quarantine  at  Marseilles,  on  his  return  to  France, 
had  been  attacked  with  an  inflammatory  ophthalmia,  which 
being  attended  by  violent  pains  in  the  head,  had  deprived  him 
completely  of  the  light  of  day,  and  was  finally  transferred  to 
the  hospital  of  the  consular  guards.     All  the  inflammatory 


316  Egyptian  Ophthalmia. 

symptoms  had  then  disappeared;  his  eyes,  however,  were 
more  protruding  than  in  their  natural  condition,  and  the 
iris  was  motionless.  If  the  patient  felt  there  but  slight 
pains,  he  had  a  keen  and  permanently  painful  sensation  against 
the  bottom  of  the  orbits,  and  along  the  course  of  the  frontal 
sinuses.  His  frame  was  impoverished  and  his  moral  constitu- 
tion much  afiected.  After  five  or  six  months  most  careful 
attention  having  been  bestowed  upon  him,  and  after  having 
employed  the  remedies  most  indicated,  he  finally  died  of 
marasmus. 

On  inspecting  his  corpse,  we  found  the  ball  of  both  eyes 
tumefied;  the  crystalline  lens  had  become  somewhat  opaque; 
the  internal  surface  of  the  choroid  coat  was  of  a  yellowish 
colour,  the  retina  disorganised  (réduite  en  putrilage),  the 
optic  nerves  atrophied;  the  periorbit  and  a  part  of  the  dura 
mater,  lining  the  anterior  fossse  of  the  base  of  the  cranium, 
were  detached,  and  the  osseous  spots,  denuded  of  these  mem- 
branes, were  in  a  carious  state.  The  substance  of  the  brain 
was  softened,  and  its  cavities  or  ventricles  filled  with  serum. 

Nevertheless,  on  acting  upon  the  rules  laid  down  in  the 
course  of  this  memoir,  by  means  of  the  prophylactic  precau- 
tions which  our  soldiers  by  degrees  learnt  to  adopt,  and  in 
consequence  of  their  becoming  acclimated,  the  result  had  been 
that  ophthalmia  became  of  much  less  frequent  occurrence, 
and  that  its  effects  were  felt  scarcely  any  longer. 

Several  soldiers  of  our  expedition,  without  having  been 
attacked  by  ophthalmia,  were  suddenly  struck  with  almost 
total  blindness,  upon  the  occasion  of  the  precipitate  transition 
from  the  burning  climate  of  Africa  to  that  of  Europe,  during 
the  rigid  season  of  winter. 

It  would  be,  therefore,  a  matter  of  great  moment  for  the 
health  of  soldiers,  not  merely  in  this  respect,  but  for  number- 
less other  reasons,  that  they  should  not  be  suffered  to  go  from 
one  climate  to  another  of  an  opposite  character,  except  in  such 
seasons,  when  both  climates  have  a  nearly  equal  temperature; 
or  if  circumstances  should  require  a  departure  from  this  rule, 
every  necessary  precaution  should  be  taken  to  prevent  the 
consequences  of  the  extreme  diflerencc  of  temperature  and  of 
their  pernicious  tendency. 


Egyptian  Ophthalmia.  317 

After  all  that  we  have  said  upon  the  suhject  of  ophthalmia, 
it  will  no  doubt  be  easily  understood  that,  in  order  to  be  proof 
against  it  in  Egypt,  as  well  as  in  those  countries  and  seasons 
whose  atmospheric  characteristics  resemble  those  of  the  former, 
it  is  necessary  to  avoid  the  direct  impression  of  light  and 
dust  upon  the  eyes  in  day-time;  to  be  sufficiently  covered  from 
head  to  feet,  at  night,  and  to  wear  a  cloth  over  the  eyes;  to 
keep  as  much  as  possible  at  a  distance  from  damp  and  swampy 
places,  and  to  keep  up  perspiration  and  sweating  by  bathing 
during  the  proper  season,  and  by  exercise.  Care  also  should 
be  taken  to  abstain  from  the  inordinate  use  of  wine  and  spirit- 
uous liquors,  and  from  food  of  a  heating  nature  and  difficult 
digestion;  to  support  the  tone  of  the  stomach,  which  in  very 
hot  climates  is  always  easily  debilitated,  by  means  of  tonics, 
such  as  coffee,  and  some  bitter  infusion,  which  may  be  taken  in 
the  morning;  and  finally,  to  wash  the  eyes  and  the  whole  head 
frequently  with  fresh  water  and  vinegar. 

Of  Epilepsy. 

To  the  description  of  the  diseases  already  given,  I  now  pro- 
pose to  annex  some  observations  which  we  have  made  on  the 
subject  of  cerebral  epilepsy. 

Epilepsy,  notwithstanding  the  assertion  generally  admitted 
by  writers,  is  by  no  means  always  beyond  the  resources  of 
medicine.  The  object  most  difficult  of  attainment,  in  study- 
ing this  disease,  is  the  knowledge  of  the  nature  of  its  exciting 
cause  and  of  the  organs  which  it  affects  more  especially.  In 
tracing,  however,  with  care,  the  career  of  the  symptoms  whicli 
chai'acterize  the  accession  of  an  epileptic  fit,  it  is  easy  enough 
to  distinguish  the  principal  species  of  this  disease.  That 
which  authors  designate  under  the  name  of  idiopathic  or 
encephalic  epilepsy,  because  it  has  its  seat  in  the  head  or  spi- 
nal marrow,  may  be  readily  distinguished  from  that  species, 
termed  sympathetic,  which  may  be  seated  in  any  other  part 
of  the  body:  1,  by  an  examination  of  the  causes  which  have 
excited  the  disease;  2,  by  the  nature  and  career  of  the  symp- 
toms which  it  exhibits;  3,  by  the  pathological  condition  of 
the  parts  affected. 


318  Of  Epilepsy. 

In  the  first  place,  epilepsy  may  be  occasioned  either  by 
some  defect  or  original  malformation  of  the  head  and  spinal 
column  (being  in  that  case,  of  course,  of  a  congenital  nature), 
or  it  may  be  the  result  of  some  pathological  derangement, 
spontaneously  developed,  or  produced  by  an  external  cause  in 
the  bones  of  the  cranium,  in  the  meninges,  in  the  brain  itself, 
or  in  the  spinal  marrow.  Each  of  these  lesions  is  charac- 
terized by  particular  symptoms.  The  first,  which  roost 
frequently  may  be  referred  to  hypertrophiaof  the  bones  of  the 
cranium,  manifests  itself  by  an  unnatural  exuberance  at  several 
places  of  its  surface,  most  usually  of  the  vertex  or.  superior 
part,  as  we  have  observed  in  numerous  instances.  There  pre- 
vails in  this  case  an  habitual  heaviness  of  the  head,  together 
with  an  irresistible  tendency  to  sleep;  the  features  of  the  coun- 
tenance become  changed,  and  the  patient  falls  into  a  state 
of  stupor.  The  fits  come  on  in  a  slow  and  gradual  manner, 
and  always  announce  themselves  by  disturbance  of  the 
mental  faculties  and  by  loss  of  consciousness.  They  are 
commonly  not  very  violent,  but  of  long  duration,  and  on  their 
cessation  the  patients  never  remember  any  of  the  occurrences 
which  have  passed. 

It  is  evident  that  in  this  variety  of  epilepsy  it  is  the 
periphery  of  the  brain  which  suffers,  in  consequence  of  the 
pressure  exerted  upon  its  surface  by  the  roof  of  the  cranium, 
the  cavity  of  which  diminishes  in  proportion  to  the  degree  of 
the  thickening  of  its  parietes.  The  periodical  return  of  the 
fits  depends  upon  the  reaction  of  the  organs  against  the  obsta- 
cles opposed  to  them;  sometimes,  however,  there  are  concomi- 
tant causes  by  which  they  are  occasioned. 

If  the  disease  be  settled  in  the  meninges,  it  will  be  more 
difficult  to  judge  of  the  complaint,  unless  there  be  fungous 
growths  upon  the  dura  mater,  which,  having  perforated  the 
bones  of  the  cranium,  project  through  them  outwards^ 
The  symptoms  of  this  particular  aflfection  bear  a  great  analogy 
to  those  of  that  species  of  epilepsy  which  results  from  hyper- 
trophia  of  the  bones  of  the  cranium.  When  the  fungi,  after 
having  perforated  the  bones,  form  perceptible  tumours  under- 
neath the  integuments  of  the  head,  nature  must  be  suffered  to 


Of  Epilepsy.  319 

tate  her  own  course  and  every  operation  upon  tliem  should  be 
carefully  avoided. 

The  vertebral  column  likewise  may  sustain  unnatural  inflex- 
ions or  incurvations  to  a  greater  or  lesser  extent.  One  of  tbe 
last  dorsal  vertebrae  may  have  undergone  an  instantaneous,  a 
sudden  or  gradual  displacement,  and  produce  a  corresponding 
change  of  the  spinal  marrow.  This  alteration  is  easily 
detected  in  this  species;  for  just  before  the  fit,  the  patient  ex- 
periences a  kind  of  shivering,  attended  by  smart  pains  in  the 
back,  and  immediately  afterwards  he  sinks  upon  his  knees, 
&c.  The  prognosis  in  this  species  of  epilepsy  is  exceedingly 
discouraging,  because  art  possesses  scarcely  any  resources 
wherewith  to  relieve  it;  however,  if,  after  having  destroyed 
the  spontaneous  morbid  causes  in  those  cases  in  which  they 
may  exist,  there  remains  only  the  mechanical  cause  to  be  over- 
come; such  as  an  unnatural  deviation  or  projection  of  the 
vertebrae;  favourable  results  might  perhaps  be  obtained  from 
the  application  of  the  moxa,  which  so  preeminently  possesses 
the  property  of  restoring  the  action  of  enfeebled  organs,  and 
which  might  also  promote  slowly  and  gradually  the  approxi- 
mation of  the  separated  or  displaced  bones,  in  behalf  of  which 
nature  herself  is  incessantly  engaged.  The  epileptic  symp- 
toms become  mitigated  and  diminish  in  the  same  proportions, 
and  the  disease  may  finally  disappear  altogether.  In  all  case» 
topical  revulsives,  such  as  the  various  methods  of  cauterization,^ 
if  applied  carefully  and  under  proper  precautions,  change 
the  mode  of  the  morbific  process;  resolution  takes  place  in  the 
osseous  exuberances;  the  brain  or  the  spinal  marrow  are  no 
longer  compressed,  and  the  equilibrium  of  the  encephalic  func- 
tions is  restored.  But  it  is  of  great  consequence,  as  we  have 
said  before,  to  subdue  in  the  first  place  the  particular  morbid 
causes,  before  undertaking  any  external  application. 

Epilepsy  arising  from  a  change  of  structure  of  some  or  more 
places  in  the  brain,  presents  commonly  remarkable  anomalies, 
according  to  the  seat  of  the  disease.  Thus,  for  example,  when 
this  happens  to  be  on  some  place  of  the  periphery  of  this  or- 
gan, the  patient  first  loses  his  consciousness,  immediately  after 
which  he  is  seized  with  convulsions;   the  fits  are  violent  and 


320  Of  Epilepsy. 

follow  jeach  other  in  rapid  succession.  If,  however,  the  injury 
be  settled  in  the  ventricles  or  at  the  base  of  the  brain,  the 
downfall  of  the  person  is  the  first  symptom  which  manifests 
itself,  and  of  which  he,  being  previously  aware  of  its  approach, 
informs  his  assistants.  The  contractions  or  contorsions  of  the 
limbs  come  on  forthwith  and  assume  more  or  less  violence. 
In  epileptic  individuals  of  this  degree,  the  features  of  the 
countenance  undergo  a  change  likewise,  and  they  incessantly 
perform  a  series  of  automatic  movements  which  are  indepen- 
dent of  the  will. 

After  this  we  shall  now  devote  a  few  moments  to  the 
consideration  of  idiopathic  epilepsy  which  is  by  far  the  most 
common  kind,  and  which  depends  on  some  mal-formation  or 
fault  of  organization  of  the  bones  of  the  cranium,  or  on  some 
pathological  aSection,  acquired  and  settled  at  some  point  of 
their  substance,  either  by  foreign  bodies,  or  by  changes  ac- 
complished by  the  action  of  a  certain  virus,  as  the  syphilitic 
virus,  for  instance.  But  in  describing  this  species  of  affection 
we  shall  say  here  a  few  words  on  the  means  of  distinguishing 
the  symptoms  of  genuine  epilepsy  from  those  which  may  be 
observed  in  some  persons  capable  of  simulating  it,  and  we  in- 
tend to  demonstrate  the  efficacy  of  several  remedies  employed 
for  this  disease,  after  the  successful  result  obtained  from  their 
use  in  some  analogous  aflections. 

It  is  not  always  very  easy  for  a  physician  of  limited  ex- 
perience to  distinguish  correctly  between  these  symptonis, 
because  there  are  individuals  who,  in  order  to  escape  from  the 
profession  of  arms,  will  be  able  to  sustain  the  strongest  tests, 
without  evincing  the  slightest  sign  of  pain. 

I  believe  it  will  be  sufficient  to  reflect  for  one  moment  only 
on  the  voluntary  or  involuntary  mode  of  action  of  the  animal 
functions,  and  carefully  to  examine  the  phenomena  attendant 
on  the  paroxysms  of  the  disease,  in  order  to  distinguish 
between  true  and  feigned  epilepsy.  These  phenomena  may 
be  divided  into  permanent  signs,  or  signs  accompanying  the  fit. 
The  former  are  equivocal,  where  the  disease  is  of  recent  date, 
as  in  feigned  epilepsy;  but  where  the  complaint  is  of  a  chronic 
or  hereditary  nature,  a  train  of  more  or  less  perceptible  symp- 


Of  Epilepsy.  331 

tomswill  become  fixed  and  announce  their  presence  externally, 
which  the  practitioner  will  at  once  recognise  and  promptly 
investigate. 

M.  Dumas,  a  celebrated  professor  of  the  university  of 
Montpelicr,  used  to  consider  the  prolongation  of  the  facial 
triangle  as  a  constant  and  pathognomic  sign.  Without  pre- 
suming to  question  such  an  assertion,  otherwise  higiily 
respectable,  in  my  opinion,  I  will  only  indulge  the  remark 
that  in  order  to  effect  a  change  of  this  kind  in  the  contour  of 
the  face,  it  must  be  supposed  that  the  disease  had  existed  from 
the  infancy  of  the  individual,  and  that  it  had  been  occasioned 
by  some  organic  defect  in  the  substance  of  the  superior  maxil- 
lary bones,  so  as  to  cause  the  facial  angle  to  swell  out  in 
proportionate  degrees.  It  is,  however,  most  usually  in  the 
bones  of  the  cranium,  in  the  meninges  or  in  the  brain  itself 
that  the  cause  of  epilepsy  is  seated  j  therefore  the  alteration  of 
these  parts  cannot  exert  any  influence  upon  the  conformation 
of  the  face,  excepting  in  consequence  of  rachitis  or  of  any 
other  defect  in  the  development  of  the  bones  composing  it. 
That  this  angle  should  be  less  open  in  some  epileptic  person, 
may  be  easily  understood;  and  it  is  well  known  that  in  the 
negro,  in  whom  the  facial  angle  is  more  acute  than  in  the  Euro- 
pean, the  powers  of  intellect  are  more  obtuse  also,  and  yet  it 
cannot  be  conclusively  inferred  that  the  prolongation  of  this 
part  should  be  a  cause  of  epilepsy.  Besides,  it  is  an  unprofitable 
business  to  look  in  geometrical  variations  of  the  countenance 
for  the  positive  marks  of  a  disease  w^hich  we  can  hardly  ascer- 
tain by  any  other  bearings  than  those  which  anatomy  and 
physiology  furnish  us  with,  and  which  are  more  or  less  con- 
stant. 

In  that  species  of  epilepsy  which  engages  our  attention  at 
present,  and  which  originates  in  the  head,  the  brain  is  directly 
or  indirectly  altered,  and  hence  all  the  phenomena  which  cha- 
racterize its  fits.  These  are,  as  we  have  said  before,  a  dull 
pain  in  the  head,  vertigo,  the  downfall  of  the  person  when  in 
the  erect  position,  change  of  the  moral  faculties,  like  those  of 
the  voice,  of  speech  and  of  vision,  the  eyes  become  more  or 
less  distorted,  and  the  muscles  contract  involuntarily  and  con- 
2  Q 


322  Of  Epilepsy. 

vulsively.  All  these  symptoms  may  be  feigned,  especially 
when  the  individual  has  been  in  the  habit  of  so  doing;  but  he 
cannot  imitate  the  emission  of  thick  and  frothy  saliva  which 
is  freely  secreted  during  the  fit,  nor  the  dilatation  of  the  pupils, 
independent  of  the  will  of  the  person. 

In  genuine  epilepsy  the  pulse  is  calm  and  scarcely  tremu- 
lous; in  the  other,  on  the  contrary,  it  is  agitated  as  well  as  the 
perspiration;  the  contraction  of  the  muscles  is  also  less  simul- 
taneous than  in  the  real  kind,  and  it  does  not  depend  upon  the 
individual  to  distort  his  eyes,  as  is  done  spontaneously  in  the 
former. 

Inasmuch  as  this  disease  exerts  its  principal  influence  upon 
the  nervous  system  of  relation,  it  disorders  its  functions  and 
paralyses  them,  from  which,  moreover,  results  a  decline  of 
the  moral  faculties,  an  involuntary  sinking  of  the  superior 
eye-lids  and  an  inclination  of  the  head  forwards,  owing  to  the 
trifling  power  of  contraction  of  its  extensor  muscles,  which 
imparts  a  stupid  look  to  the  countenance;  the  walk  of  the  in- 
dividual is  unsteady  and  staggering. 

These  symptoms,  sometimes  more  and  sometimes  less  dis- 
tinct, are  always  present  in  the  species  of  epilepsy  of  which 
we  have  spoken,  particularly  if  the  disease  is  hereditary  or 
chronic,  and  no  one,  be  he  ever  so  little  practised,  can  be  mis- 
taken by  it. 

The  question  now  arises,  whether  it  be  possible  to  attack 
with  any  hope  of  success  the  organic  injury  of  the  cranium  or 
of  the  membranes  of  the  brain?  I  believe,  yes;  and  the  facts 
which  I  am  presently  going  to  relate  confirm  me  in  this  opin- 
ion. It  is  on  this  account  not  necessary  to  regulate  the  fits  or 
to  fix  their  periodical  recurrence,  which  besides  is  not  always 
within  the  power  of  the  physician,  unless  the  epilepsy  be  of 
an  accidental  or  sympathetic  kind;  but  the  internal  exhibition 
or  the  external  application  of  certain  substances,  possessing  the 
property  of  dissolving  the  osseous  or  lymphatic  tumours,  such 
as  swellings  of  the  bones,  exostoses,  fungous  growths  of  the 
membranes  and  their  induration,  may,  by  destroying  the 
cause,  induce  the  disappearance  of  the  disease  and  the  cessa- 
tion of  its  effects. 

The  remarkable  and  unexampled  success  which  I  have  met 


Of  Epilepsy.  323 

with  in  obstinate  venereal  exostoses  from  mercurial  frictions 
to  the  soles  of  the  feet,  at  considerable  intervals  of  time,  from 
the  exhibition  of  drinks  acidulated  with  muriatic  alcohol,"*  and 
from  blisters  applied  over  these  tumours,  has  induced  me  to 
think  that  the  same  remedies  might  be  employed  with  similar 
advantage  no  doubt  in  cases  of  exostoses  of  the  cranium,  or  in 
indurations  of  the  dura  mater  which  are  usually  so  apt  to  pro- 
duce and  to  keep  up  epilepsy;  it  is,  however,  not  sufficient 
merely  to  try  these  remedies;  they  must  be  persevered  in  for 
a  long  time  with  such  modifications  as  circumstances  may 
require,  but  above  all,  after  the  virus  has  been  destroyed,  the 
repeated  application  of  revulsives  should  be  insisted  upon. 

The  following  cases  will,  I  trust,  inspire  some  confidence  in- 
favour  of  these  remedies. 

First  Observation.  Louis  Lombardi,  twenty-two  years 
old,  a  grenadier  in  the  imperial  ex-guards,  entered  the  hospital 
on  account  of  two  anomalous  tumours  upon  the  head,  with 
some  little  fluctuation  and  redness  of  the  skin.  This  man  felt 
a  steady  pain  in  the  parts  affected,  and  was  in  a  state  of  drowsi- 
ness and  had  frequent  fits  of  epilepsy. 

Both  tumours  being  opened  with  a  sharp  instrument,  we 
discovered  an  extensive  carious  surface  on  the  cranium,  cor- 
responding with  these  small  abscesses.  The  internal  table  of 
the  bones  was  perforated,  and  the  dura  mater  was  perceived  to 
pulsate  slightly  through  the  openings.  The  discharge  of  mat- 
ter contained  in  the  abscesses  and  depressing  the  dura  mater, 
had  relieved  the  patient;  the  epileptic  fits  became  less  frequent 
and  were  of  much  shorter  duration;  but  the  caries  continued 
to  go  on  and  the  symptoms  became  more  aggravated.  An 
epileptic  fit  could  be  reproduced  at  will  by  immediate  press- 
ure on  some  of  the  fungous  growths  of  the  dura  mater,  which 
made  their  appearance  through  the  carious  openings;  these 
fungi  were  of  proportionate  size  to  the  openings;  at  length  the 
patient  died  on  the  thirtieth  day  after  admission  into  the  hos- 

*  The  new  tianslation  of  the  French  Pharmacopoeia  by  M.  Ratier,  p.  371,  has 
the  following  formula  for  muriatic  alcohol: 

Take  of  muriatic  acid,  (22  degrees)  120 

Alcohol,  (26—30  degrees)       360 

Mix  and  preserve  for  use  in  well  secured  bottles.     Transi. 


324  Of  Epilepsy. 

pital.  On  opening  his  body,  we  discovered,  in  fact,  twa 
fungous  tumours  in  the  dura  mater  which  appeared  to  have 
been  produced  by  a  cause*  similar  to  those  which  had  pro- 
duced the  caries.  Both  these  tumours  pressed  upon  the  brain 
in  corresponding  situations,  which  circumstance  had  occasioned 
the  epileptic  attacks. 

The  analogy  which  I  have  found  to  exist  between  these 
tumours  and  those  which  are  accompanied  also  by  caries  of  the 
bones  of  the  cranium,  which  were  occasioned  by  a  well  known 
syphik'tic  cause  and  which  in  several  instances  I  have  success- 
fully treated  by  anti-venereals  and  muriatic  acid,  has  inclined 
me  to  the  belief  that  the  fatal  issue  in  the  case  of  Lombardi, 
might  have  been  averted  by  the  same  remedies,  if  they  could 
have  been  employed  in  proper  season. 

Second  Observation.  Bartholomew  Thevenot,  a  fusilier 
chasseur,  26  years  old,  came  to  the  hospital  to  be  cured  of 
two  enormous  tumours  of  a  scrofulous  aspect  which  were 
situated  on  the  neck  and  accompanied  by  pain  in  the  head  and 
by  epileptic  fits,  to  which  he  stated  to  have  been  subject  for 
several  years  past. 

The  notes  we  took  at  the  bedside  of  this  soldier,  in  order  to 
learn  the  cause  of  his  complaint,  informed  us  that,  in  1802,  he 
had  had  syphilis  which  he  supposed  had  been  properly  treated. 
A  gun  shot  wound  which  he  had  received  six  years  later, 
when  he  was  with  the  army  in  Spain,  and  the  ball  of  which 
had  struck  the  anterior  part  of  the  thigh,  had  been  followed 
by  typhus  fever  and  hospital  gangrene.  About  the  time  of 
the  cicatrization  of  the  wound,  he  suffered  from  violent  head- 
ach  which  did  not  subside  until  a  spontaneous  purulent  dis- 
charge from  the  ear  had  been  established,  after  the  fourth 
month  of  his  stay  in  the  hospitals.  The  discharge  having 
been  suppressed  some  time  afterwards,  he  was  troubled  by  an 
unpleasant  ringing  noise  in  the  same  ear  and  by  deafness;  he 
became  subject  to  vertigo  and  to  occasional  slight  fits  of 
epilepsy.     In  this  state  he  arrived  in  the  fever  wards  of  the 

*  The  patient  could  never  give  a  satisfactory  answer  to  the  questions  put  to 
hica  in  order  to  ascertain  this  cause;  but  there  was  reason  to  believe  that  it  had 
been  the  result  of  a  syphilitic  virus,  considering  that  he  bore  the  marks  of  ils 
effects. 


Of  Epilepsy.  325 

hospital  of  the  guards.  The  application  of  some  leeches  to  the 
temples,  of  blisters  behind  the  ears,  and  the  exhibition  of 
internal  remedies,  appeased  these  symptoms  and  promoted  the 
formation  of  an  abscess  or  bubo  in  the  groin,  the  suppuration 
of  which  was  unluckily  dispersed  by  resolvent  remedies. 
From  this  moment  the  epileptic  attacks  followed  each  other  in 
rapid  succession  and  became  more  violent;  the  glands  of  the 
neck  became  engorged,  and  two  or  three  of  them  suppurated. 
In  this  condition  the  patient  had  been  transferred  to  my  own 
wards.  Always  suspicious  of  the  presence  of  a  syphilitic 
cause,  I  prescribed  for  him  anti-venereal  in  conjunction  with 
anti-scrofulous  remedies.  Fluctuation  becoming  evident  in 
both  these  tumours,  I  directed  the  caustic  potash  to  be  applied 
to  them.  On  the  sloughs  coming  off  several  days  afterwards, 
the  patient  was  suddenly  attacked  in  the  middle  of  the  night 
by  a  violent  epileptic  fit,  which  was  succeeded  by  complete 
hemiplegia  of  the  left  side,  by  the  almost  total  loss  of  his  in- 
tellectual faculties  and  the  use  of  his  senses.  Notwithstanding 
his  inclination  to  stupor,  the  patient  pointed  to  a  painful  spot 
in  the  hypochondriac  region  of  the  paralysed  side.  The  ap- 
plication of  a  large  blister  over  it  relieved  him  momentarily, 
and  the  epileptic  fits  were  interrupted.  The  hemiplegia, 
however,  remained  always  the  same,  that  is  to  say,  the  two 
paralysed  limbs  continued  to  be  deprived  of  the  powers  of 
motion  and  of  sensation.  A  few  days  later  the  headach 
returned,  as  well  as  the  epileptic  attacks.  The  patient  being 
in  imminent  danger  of  death,  I  ordered  the  application  of  a 
blister  to  the  head.  The  head  being  shaved,  a  considerable 
prominence  was  observed  on  its  right  side,  which  was  formed 
by  the  squamous  portion  of  the  temporal  and  lower  half  of  the 
parietal  bone.  Another  prominence  on  the  top  of  the  cranium 
gave  to  the  cranium  a  conical  shape.  The  first  blister  cover- 
ing the  scull-cap  produced  a  sensible  improvement,  after 
which  I  prescribed  for  him  an  infusion  of  valerian  with  the 
stimulant  addition  of  muriatic  alcohol,  some  boluses  of  cam- 
phor and  opium  for  the  night,  and  an  anti-syphilitic  liquor, 
one  ounce  to  be  taken  every  morning  in  milk.*     I  increased 

*  This  liquor  consists  of  oxymuriate  of  mercury,  muriate  of  ammonia  and 


326  Of  Epilepsy. 

the  dose  of  camphor  by  degrees  to  sixteen  grains  (un  gramme) 
a  day.  The  headach  subsided,  the  paralysis  diminished  per- 
ceptibly and  the  fits  did  not  return.  Some  new  abscesses, 
however,  having  formed  on  the  neck,  I  ordered  the  caustic 
potash  to  be  applied  upon  the  fluctuating  spots  of  these  tumours; 
another  blister  was  put  to  the  nape  of  the  neck,  and  a  third  one 
over  the  tumour  formed  by  the  temporal  bone. 

Sensation  and  motion  gradually  revived  in  the  paralysed 
limbs.  The  patient  recovered  daily  more  and  more  the  use 
of  his  senses  and  intellectual  faculties,  but  still  he  was  period- 
ically subject  to  shiverings  of  the  left  side  of  the  body,  which 
succeeded  to  a  tremulous  motion  from  the  extremities  to  the 
head.  This  phenomenon  occurred  more  particularly  in  tem- 
pestuous weather. 

The  suppuration  of  the  sores  of  the  neck  having  been  stop- 
ped again  from  causes  which  remained  unknown  to  me,  he 
had  a  new  attack  of  epilepsy,  which,  however,  was  of  but 
short  duration.  I  hastened  to  re-establish  the  suppuration  of 
the  scrofulous  ulcers,  and  directed  a  fourth  blister  to  be  applied 
over  the  tumour  of  the  temple.  I  increased  the  dose  of  cam- 
phor still  further.  All  these  measures  produced  excellent 
effects,  and  the  patient  made  rapid  progresses  towards  recovery; 
nevertheless,  after  a  short  lapse  of  time,  several  very  violent 
attacks  of  epilepsy  came  on  again,  but  were  of  shorter  dura- 
tion. The  application  of  the  blisters  to  the  head  was  repeated, 
in  addition  to  which  I  had  put  some  also  to  his  right  arm. 

One  day  during  my  morning  visit  he  had  a  terrible  fit, 
accompanied  with  convulsions  and  an  extreme  sinking  of  his 
vital  powers.  I  directed  yet  an  eighth  blister  to  be  applied  to 
the  temple;  and  in  addition  to  the  powerful  anti-spasmodics 
which  the  patient  was  taking,  I  gave  him  bark  in  substance  in 
generous  wine  and  ether;  for  the  blister  upon  the  arm  I  sub- 
stituted an  issue  which  he  has  kept  open. 

Ever  since  the  last  mentioned  fit  Thevenet  has  not  been  trou- 
bled again;  the  paralytic  affection  has  yielded  completely,  and 

opium,  ââ  10  grains,  to  be  dissolved  in  the  necessary  quantity  of  Hoffman's 
anodyne  liquor,  suspended  in  a  quart  of  distilled  water. 


Of  Epilepsy.  327 

he  has  by  degrees  recovered  the  integrity  of  his  physical  and 
moral  functions.  The  sores  of  his  scrofulo-venereal  ulcers 
have  cicatrized;  the  bony  prominences  of  the  cranium  have 
disappeared  and  the  head  has  regained  its  looks  (faciès)  and 
its  natural  outlines.  In  fine,  I  believe  that  this  soldier  has 
been  for  ever  released  and  perfectly  cured  of  a  disease  which 
is  generally  considered  incurable,  particularly  where  it  has 
reached  to  such  a  degree  as  in  the  subject  of  this  observation. 

Third  Observation. — Dutertre,  a  rifleman,  44  years  of 
age,  had  been  for  about  a  year  subject  to  fits  of  cerebral  epi- 
lepsy in  frequent  repetition.  In  consequence  of  a  fall  which 
he  had  upon  the  head,  at  the  commencement  of  one  of  his 
latest  attacks,  he  had  ruptured  the  vessels  of  communication 
of  the  integuments  of  the  right  temporal  region  with  the  tem- 
poral apophysis,  the  results  of  which  had  been  a  sero-sanguineous 
effusion,  inflammation  and  an  enormous  collection  of  matter, 
on  account  of  which  he  had  been  brought  to  the  hospital  of 
the  guards.  Emollients  were  employed  for  several  days,  and 
as  soon  as  the  fluctuation  of  the  abscess  had  become  distinct,  I 
opened  it  by  making  a  deep  incision  into  it:  a  great  quantity 
of  pus  was  discharged  from  it,  and  from  that  moment  the 
patient  felt  relieved.  I  put  him  upon  the  use  of  a  ptisan  of 
valerian,  in  conjunction  with  the  muriatic  acid  and  the  cam- 
phor and  opium  boluses,  the  dose  of  the  former  being  gradually 
increased  to  sixteen  grains  a  day. 

The  wound  was  cleansed  and  had  cicatrized;  the  countenance 
of  the  patient,  which  had  been  already  much  changed  at  the 
time  of  his  entrance  into  the  hospital,  had  resumed  its  shape 
and  usual  expression;  he  has  not  had  another  attack  of  this 
disease,  and,  like  Thevenet,  has  acquired  even  some  embon- 
point. The  abscess  which  had  formed  under  the  integuments, 
had  doubtless  produced  the  same  efiects  in  the  one  as  the 
blisters  in  the  other. 

Fourth  Observation.— Francis  Picot,  24  years  old,  of 
lymphatic  temperament,  a  private  of  the  second  regiment  of 
infantry  of  the  guards,  had  been  admitted  into  the  hospital,  on 
October  Sth  1821,  on  account  of  epileptic  fits,  which,  for  seve- 
ral months  past,  had  become  more  frequent.     His  disease  had 


328  Of  Epilepsy. 

been  occasioned  by  bypcrtrophia  of  the  cranium,  which  might 
be  ascertained  by  simply  comparing  the  thickness  of  this  bony 
cap  to  the  stature  and  slender  proportions  of  the  patient;  but 
the  dull  pains  which  he  felt  in  the  head,  chiefly  at  its  superior 
part,  the  impossibility  of  his  bearing  upon  it  any  object  of  the 
least  weight,  the  restraint  which  he  felt  there  under  the  influ- 
ence of  pressure  from  the  hand,  of  ever  so  short  a  duration, 
still  better  confirmed  the  existence  of  the  morbid  changes 
alluded  to.  The  other  symptoms  of  cerebral  epilepsy  were 
particularly  striking  in  this  man;  decline  of  the  mental  facul- 
ties, languid  eyes,  the  upper  eye-lids  involuntarily  sunk,  the 
head  inclined  forwards,  besides  which,  the  patient  was  sad  and 
silent;  his  face,  however,  had  some  colour,  and  a  serious  oph- 
thalmia of  a  purulent  nature  had  manifested  itself  several 
months  since. 

The  epilepsy  of  Picot  was  of  very  long  standing;  it  had 
existed  from  eight  to  nine  years,  with  intervals  of  a  year  or 
eighteen  months  between  without  having  a  single  attack. 
Nothing  of  any  great  moment,  such  as  concussions,  wounds, 
falls  or  frights  having  occurred  to  give  rise  to  it,  the  original 
cause,  therefore,  could  be  referred  only  to  the  repulsion  of  an 
itch,  cured  in  three  days  by  a  village  shepherd,  in  as  much  as 
thispsoric  affection  is  the  only  disease  by  which  Picot  remem- 
bers to  have  been  attacked,  and  as  the  first  epileptic  fit  did 
not  happen  until  after  the  cure  of  the  itch.  Other  circumstan- 
ces seemed  further  to  confirm  these  suspicions,  for  instance 
that  from  one  time  to  another,  and  particularly  during  the  hot 
summer  months,  Picot's  body  became  covered  with  pimples, 
m-ore  numerous  sometimes  than  at  others,  and  disappearing 
again  as  readily  as  they  had  sprung  up.  These  pimples  occa- 
sionally caused  an  itching  sensation;  and  on  puncturing  them 
there  was  generally  nothing  discharged  but  a  little  serum.  In 
addition  to  this,  we  ought  to  consider  that,  while  these  erup- 
tions continued  on  his  body,  the  health  of  our  patient  was 
always  much  better,  and  that  he  was  then  free  from  fits. 

Depletion  from  the  jugular  vein,  cups  to  the  temples  and 
to  both  sides  of  the  spinal  column,  were  the  measures  first 
employed,  after  which  the  head  was  shaved  and  a  large  blister 


Of  Epilepsy.  329 

applied  over  the  surface  of  the  base  of  the  cranium.  Notwith- 
standing this,  he  had  another  epileptic  fit  a  few  days  afterwards; 
but  in  that  there  was,  indeed,  nothing  surprising,  as  for  the 
last  five  or  six  months  the  fits  had  assumed  a  periodical  cha- 
racter. A  ptisan  of  acidulated  barley  gruel  was  prescribed 
for  the  patient,  together  with  extracts  of  valerian,  taraxacum, 
fumaria  officinalis  and  a  small  quantity  of  aloes;  a  pill  com- 
posed of  camphor  and  nitre,  in  doses  gradually  augmented,  and 
antispasmodic  draughts  were  given.  More  cups  and  fresh 
blisters  were  applied  to  both  sides  of  the  spine,  which  soon 
afterwards  were  succeeded  by  the  application  of  two  grains  of 
potash  to  the  base  of  the  cranium,  the  sores  resulting  from 
which  were  converted  into  issues. 

Under  the  influence  of  this  revulsive  treatment  the  condition 
of  the  patient  seemed  to  improve.  At  the  beginning  of 
November,  having  observed  upon  the  top  of  the  head  two 
spots  somewhat  fluctuating,  which  could  easily  be  depressed 
with  the  finger,  it  was  judged  proper  to  establish  there  two 
sloughs  with  the  potash,  for  the  purpose  of  aiding  the  stimu- 
lating action  of  the  discharges  at  the  base  of  the  cranium;  and 
inasmuch  as  by  these  means  the  well-being  of  the  patient 
was  so  much  further  improved,  that  the  ophthalmia  had  been 
considerably  tranquillized,  these  two  latter  applications  were 
soon  after  succeeded  by  a  third  of  the  same  substance  on  some 
other  convenient  place  of  the  top  of  the  head. 

However,  on  the  15th  of  November  Picot  was  attacked  a 
second  time,  since  his  admission  into  the  hospital,  which  in 
its  duration  and  violence  was  greatly  reduced  from  the  pre- 
ceding ones.  During  the  treatment  of  his  disease  symptoms 
of  gastric  derangement  became  developed  and  were  allayed  by 
diet  and  mild  drinks.  An  emetic  was  administered  likewise, 
and  the  relief  obtained  from  it  impressed  us  with  a  belief  in 
its  salutary  effects  under  such  circumstances.  In  fact,  the 
revulsive  measures  thus  uninterruptedly  persevered  in,  restored 
the  patient  by  degrees,  if  not  to  perfect  health,  at  least  to  a 
condition  very  near  akin  to  it.  In  December  the  ophthalmic 
disease  had  ceased  to  exist  altogether;  tranquil  in  its  appear- 
ance, the  eye  was  more  at  ease  in  its  motions,  the  upper  eye-lid 
2  R 


330  Of  Epilepsy. 

moved  upwards  with  facility,  the  slight  convulsive  motions 
which  had  been  frequently  observed  in  the  muscles  of  the 
face  and  limbs,  were  scarcely  perceptible;  a  greater  degree 
of  cheerfulness  had  taken  the  place  of  the  profound  silence 
which,  during  the  two  first  months,  he  had  almost  constantly 
observed.  The  cranium  was  evidently  reduced  under  the  in- 
fluence of  the  inciting  remedies  which  had  been  applied,  for 
the  measure  taken  of  the  different  diameters  of  the  head,  on 
the  very  day  of  admission  into  the  hospital,  amounted  then  to 
several  lines  more. 

In  order  to  add  still  further  to  the  results  thus  obtained,  or 
with  the  intention,  at  least,  not  to  lose  any  of  the  benefits  which 
had  accrued  from  them,  the  application  of  several  moxas  behind 
the  ears,  and  below  the  inferior  occipital  protuberances  was  be- 
gun, in  the  month  of  December,  and  several  mercurial  frictions 
were  directed  to  be  made  to  the  soles  of  the  feet  at  intervals 
of  from  five  to  six  days.  As  Picot  was  anxious  to  leave  the 
hospital  in  the  early  part  of  January,  an  issue  was  established 
upon  the  arm,  so  as  to  supply  and  replace  the  measures  which 
now  he  was  about  to  relinquish. 

Symptomatic  epilepsy  is  occasioned  by  the  injury  of  any 
part,  foreign  to  the  encephalon  and  its  dependencies,  or  by 
the  presence  of  some  foreign  substance  introduced  into  the 
animal  economy,  or  spontaneously  developed  there.  Among 
the  former  rank  certain  lesions  of  nerves,  of  fibrous  portions 
of  articulations,  of  tendons  or  aponeuroses,  &c.  ;  to  the  second 
class  belong  the  presence  of  certain  calculi  in  the  bladder,  of  an 
irregular  shape,  of  worms  in  the  intestines,  of  balls  or  other 
projectiles  in  various  parts  of  the  body. 

The  fits  of  these  two  kinds  of  epilepsy  are  always  preceded 
by  pain  or  shaking  which  arise  from  the  seat  of  injury,  fly 
afterwards  to  the  head,  and  bring  confusion  into  every  func- 
tion. Under  such  circumstances  the  functions  of  nutrition 
frequently  participate  in  this  derangement;  the  general  circu- 
lation and  respiration  undergo  likewise  sensible  deviations. 
After  the  true  cause  and  seat  of  the  complaint  have  been  clearly 
ascertained,  it  is  sufficiently  easy  to  fulfil  the  indications  which 
may  present  themselves. 


Of  Epilepsy.  331 

When,  after  wounds  from  fire  or  side-arms,  connected  with 
extensive  injury  or  loss  of  substance  of  the  parts  affected,  a 
cicatrix  should  form  in  which  some  nervous  filaments  are  in- 
cluded, several  instances  of  which  have  come  under  my  own 
notice,  it  will  be  sufficient  to  cauterize  with  the  red-hot  iron  or 
with  the  moxa  those  points  of  nervous  adliesion  and  to  let 
the  cicatrices  slowly  and  gradually  renew  themselves.  With 
respect  to  foreign  bodies,  whatever  may  be  their  size  and 
nature,  they  should  be  extracted  if  possible,  after  which  the 
fits  will  commonly  cease,  especially  when  the  disease  is  not 
of  very  long  standing. 

In  addition  to  the  topical  revulsives  which  are  more  or  less 
efficacious  and  active  in  every  species  of  epilepsy,  the  exhibi- 
tion of  internal  remedies,  bearing  upon  the  spontaneously 
morbid  causes  which  have  produced,  or  which  complicate  the 
disease,  ought  not  to  be  neglected.  A  weak  solution  of  nitrate 
of  silver,  the  prussic  acid  and  other  analogous  substances  have 
been  latterly  highly  extolled;  but  experience  has  taught  us  that 
these  remedies  are  not  only  incapable  of  dissolving  the  indura- 
tions of  the  cranium  or  of  the  meninges,  the  nervous  adhesions 
or  other  organic  changes,  but  that  they  often  destroy  the 
integrity  of  the  mucous  membranes  of  tlie  intestinal  canal. 
The  narcotic  poisons,  as  the  prussic  acid,  aconitum,  &c.  attack, 
especially  in  individuals  who  are  easily  excited  (impressiona- 
bles),  whatever  may  be  the  dose  in  which  they  are  ad- 
ministered, the  vital  principle,  or  neutralise  the  nervous  fluid 
and  deprive  it  of  its  properties.  The  organic  functions  are 
then  suspended,  and  the  person  may  perish  at  once,  as  we  have 
seen  several  examples  of  it.  As  to  a  solvent  or  liquefying  medi- 
cine, greater  advantages  will  be  derived  from  the  use  of  the 
muriatic  alcohol  given  in  small  doses,  in  some  appropriate 
vehicle;  and  as  to  an  anti-spasmodic,  the  exhibition  of  camphor, 
gradually  increased  to  a  large  dose,  alone  or  combined  with 
sedative  substances,  will  best  answer  this  purpose.  Finally,  the 
various  kinds  of  baths,  at  different  temperatures,  will  in  some 
cases  also  contribute  to  the  recovery  of  the  patient.  Habitual 
issues  established  at  those  places  of  the  body  which  are  most 
favourable  to  this  disease,  as  well  as  to  the  occupations  of  the 
individual,  are  almost  always  requisite. 


332  Of  Epilepsy. 

In  the  case  of  a  soldier  of  the  guards,  epileptic  fits  had 
supervened  after  an  unsuccessful  operation  performed  at  the 
bend  of  the  arm,  in  which  the  cutaneus  internus  nerve  had 
been  pricked.  At  the  beginning  of  the  fits  the  patient  experi- 
enced a  smart  pain  at  the  point  of  the  cicatrix,  accompanied 
with  a  troublesome  shaking  which  travelled  along  the  course 
of  the  nerve,  or  along  the  inside  of  the  arm  towards  the  head; 
convulsions  came  on  immediately,  as  well  as  all  the  other 
symptoms  indicative  of  these  fits.  The  application  of  one 
grain  of  potash  to  the  summit  of  the  cicatrix,  and  several  small 
moxas  put  along  the  passage  of  the  nerve,  accomplished  the 
disappearance  of  the  fits  and  restored  the  patient  to  health. 


THE  END. 


ERRATA. 

Page    11  line  19  from  above,  for  has  read  had. 
above,  for  and  read  in. 


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2 

below,  for  ancient  read  iate. 

below,  for  nain  read  brain. 

above,  after  instances  dele  the  comma. 

above,  for  ferum  read  t'errurn. 

above,  for  by  (his  read  in  this. 

below,  for  below  read  above. 

above,  for  parieties  read  paiietes. 

below,  for  maneuvre  read  manœuvre. 

above,  fur  in  the  month  of  August  read  of  the 

below,  for  on  I'ead  under.  [same  month. 

above,  after  at  least  dele  as. 

above,  for  undergoes  read  undergo. 

above,  after  which  read  had. 

below,  after  believe  read  to  instead  of  we. 

below,  after  what  read  had. 

above,  after  measured  add  one  metre. 

o6o»e,q/?er  amounted  to  add  one  metre. 

beloiv,for  supraorbital  read  supra-orbitar. 

beloiL\for  sanguineolent  read  sanguinolent. 

above,  after  restore  read  to  it. 


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